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- Topaz Plus
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 |
| Pathology | Specified tests only |
| Radiology | Long Bones, chest, trauma and basic radiology (excluding MRI & CT Scan) |
| Dentistry |
Extractions, fillings & 2 oral hygiene visits per
beneficiary including pain and sepsis as per defined list |
| Optical | 6 months waiting period, complete test, specified frames and lenses every 2 years |
| Specialist Consultations | 5 per Family per year (pre-approval required) |
| Sonar Scans (Pregnancy) | 3 scans per Beneficiary per pregnancy |
| Paramedical (Psychologists, Physiotherapists, Occupational Therapists) | 3 consultations/sessions per Family per annum |
Contributions
| Individuals |
|
|||
|---|---|---|---|---|
| Age Band | Main | Adult | Child | |
| 0 | 25 | 580 | 493 | 232 |
| 26 | 30 | 613 | 520 | 232 |
| 31 | 35 | 646 | 549 | 232 |
| 36 | 40 | 672 | 572 | 232 |
| 41 | 45 | 699 | 593 | 232 |
| 46 | 50 | 726 | 617 | 244 |
| 51 | 55 | 765 | 651 | 244 |
| 56 | 60 | 807 | 686 | 244 |
| 61 | 65 | 868 | 738 | 244 |
| 66+ |
|
933 | 792 | 244 |
| Groups |
|
|||
|---|---|---|---|---|
| Age Band | Main | Adult | Child | |
| 0 | 25 | 509 | 433 |
204
|
| 26 | 30 | 538 | 457 | 204 |
| 31 | 35 | 567 | 482 | 204 |
| 36 | 40 | 590 | 502 | 204 |
| 41 | 45 | 613 | 521 | 204 |
| 46 | 50 | 637 | 542 | 214 |
| 51 | 55 | 672 | 571 | 214 |
| 56 | 60 | 709 | 603 | 214 |
| 61 | 65 | 762 | 648 | 214 |
| 66+ |
|
819 | 696 | 214 |
|
|
Topaz Plus Student Contribution |
|
|---|---|---|
|
|
Main |
|
|
|
492 |
|
Topaz Plus 2022 Benefit Guide
3 virtual consultations per Family
|
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$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
N$365 per visit (First consultation) (Maximum tariff regardless of type of first consultation) N$295 per visit (Follow-up consultation) (Code 0125 - extended consultation every 15 minutes of part, therefore, not payable) |
|
| 2.2. Virtual Consultations (Subject to prior approval) | |||
|
|
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$3 700 per Family | |
|
|
2.5 Procedures (Out-of-Hospital) |
Specified Minor Procedures in Room only
(Requires prior approval) |
|
|
3.
|
Medical Specialists Consultations / Visits |
100%
|
5 consultations/visits per Family per annum
(0101 and 0108 only) (Code 0129 - extended consultation every 15 minutes of part, therefore, not payable) |
| 4. | Pharmacy | 100% |
|
|
|
4.1 Acute Medication/Injections
(Paid at Maximum Namibia Medicine Price on generics) |
Unlimited
(According to Topaz and Topaz Plus 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 |
|
N$700 per Family
N$120 per claim per beneficiary per day |
| 5. | Pathology |
100%
|
Specified tests |
| 6. | Radiology | 100% |
Long bones, chest and trauma and basic radiology as per defined list.
(Excluding MRI & CT Scan) |
| 7. | Basic Dentistry | 100% |
N$1 890 per Beneficiary
N$3 650 per Family (1 plastic dentures per family every 2 years) |
| 8. |
Optical |
100% |
N$1 000 per beneficiary every two years (2021/2022)
(6 months waiting period, complete test, specified frames and lenses) |
|
|
8.1 Single Vision (Inclusive of test, frame and lenses)
|
Sub-limit 8
|
|
|
|
8.2 Bifocal (Inclusive of test, frame and lenses)
(Paid at maximum Namibia medicine price on generics) |
Sub-limit 8
|
|
| 9. | Sonar Scans | 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 9 consultations per Beneficiary (2601 & 2602).
Groups have cover from date of joining. Individuals have a 9 month waiting period. |
| 11. |
Paramedical / Allied Health Professionals (Psychologists, Physiotherapists, Occupational Therapists) |
100% | 3 consultations/sessions per Family per annum |
| 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) |
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 and 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 Benefits
|
|
|
|
12.7 Prevention of Mother-to-Child Transmission (PMTCT) (excluding Milk formula) | As per National Guidelines for antiretroviral therapy | |
| Category C: Hospitalisation Benefit |
|
Private Hospital | |
|---|---|---|---|
|
Planned Procedures: Waiting period of 6 months after joining.
Emergency Cases: Immediate cover |
|||
| Overall Annual Limit | % Tariff |
Payable from the Overall Annual Limit
|
|
| 13. |
State Hospitalisation
|
100%
|
Unlimited Private Wing of State Hospital |
|
|
13.1 Accommodation and Theatre | Overall Annual Limit | |
|
|
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) | General Practitioners and Medical Specialists (In-Hospital Services) | |
| 14. | Private Hospitalisation |
100%
|
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 case of emergency hospital admissions and emergencies after-hours, weekends and public holidays. |
|
|
14.1 Accommodation and Theatre |
Overall Annual Limit
15 days per Beneficiary |
|
|
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14.2 Blood Transfusions | Overall Annual Limit | |
|
|
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 |
Overall Annual Limit
(Limited to 7 days supply only) |
|
|
|
14.5 Radiology & Pathology (In-Hospital) | Sub-limit 15 | |
| 15. |
General Practitioners & Medical Specialists (In-Hospital Services) - Additional Hospital Benefit Cover excluded |
100% |
N$25 000 per Family
(Including Radiology and Pathology) Overall Annual Limit |
|
|
Other Healthcare providers |
|
No benefit |
| 16. | Maternity |
|
Unlimited hospitalisation in state hospital
(GPs and Specialists limited to Sub-Limit 14) Groups have cover from date of joining Individuals have a 9-month waiting period |
| 17. |
Ambulance Services
|
100% | Unlimited |
|
|
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) |
N$550 per Family | |
Detailed Benefits
These rules apply for Topaz Plus.Service Availability
Please note that all benefits on Topaz Plus are only available through registered Network 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) |
| 4610 | 54610 | Helicobacter pylori stool antigen test |
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:| 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 sonar 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 (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 as an alternative when ABC cannot be tolerated. The children 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.