OVERALL ANNUAL BENEFIT
(OVERALL ANNUAL LIMIT)
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Unlimited According To Defined Primary Healthcare Protocols
Ex Gratia 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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Payable from Acute Medication/Injections |
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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 or part thereof not payable)
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2.2. GP Virtual/Telephonic Consultations
(Telephonic/virtual writing of prescriptions not payable) | Pro-rated from date of joining
Seven virtual/telephonic consultations per Beneficiary |
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2.3 Acute Medication/Injections
(Paid at the maximum Namibia medicine price on generics)
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Payable from Acute Medication/Injections |
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2.4 Chronic Medication/Injections
- Subject to Chronic Medication Registration
(Paid at the maximum Namibia medicine price on generics)
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Payable from Chronic Medication/Injections |
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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
Requires prior approval
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100%
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Five consultations/visits per Family per annum
(0101 and 0108 only)
(Code 0129 - extended consultation every 15 minutes or part thereof not payable)
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| 4. | Pharmacy
| SEP + 40%
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4.1 Acute Medication/Injections
(Paid at the maximum Namibia medicine price on generics)
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100%
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Pro-rated from date of joining N$3 000 per Beneficiary N$5 000 per Family 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 generics) | Pro-rated from date of joining
N$3 700 per Family
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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 and 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
(One plastic denture per family every two 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)
(Six-month 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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Payable from Optical Benefit
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8.2 Bifocal (Inclusive of test, frame and lenses)
(Paid at maximum Namibia medicine price on generics)
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Payable from Optical Benefit |
| 9.
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Sonar Scans
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100%
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Three scans per Beneficiary per pregnancy.
Groups have cover from the date of joining.
Individuals have a nine-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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Nine consultations per Beneficiary (2601 and 2602).
Groups have cover from the date of joining.
Individuals have a nine-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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Three 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 Available Only 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 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 and supplements)
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Unlimited
(According to Topaz and Topaz Plus HIV medicine formulary)
(Vitamins and 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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Three sessions
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12.5 Post Exposure Prophylaxis (PEP) (Rape cover and occupational injuries only) |
As per the national guidelines for antiretroviral therapy
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12.6 Pre-Exposure Prophylaxis (PrEP)
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No Benefit
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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: Groups have cover from the date of joining
Individuals have a six-month waiting period 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.
Without Pre-authorisation: No benefit will be paid 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 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 (Three 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 and Pathology (In-Hospital)
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Payable from 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.
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 (Three 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 seven days supply only)
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14.5 Radiology and Pathology (In-Hospital)
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Payable from General Practitioners and Medical Specialists (In-Hospital Services) |
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15.
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General Practitioners and Medical Specialists
(In-Hospital Services)
- Additional Hospital Benefit Cover 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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16. |
Other Healthcare providers
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No benefit
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17.
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Maternity
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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
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18.
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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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4188
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54188
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Urine dipstick per stick (irrespective of the number of tests on stick)
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443908
| 544391 | Quantitative PCR - viral load: HIV
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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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453101 - 453109
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54531 - 545320
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Hepatitis: per antigen or antibody (Maximum of three 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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| 00090 | Consumables in radiology procedures
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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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Pregnancy Sonar Scans:
Pregnancy ultrasounds are limited to three sonars 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, follow-up visit
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TARIFF CODE (039 004)
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TARIFF DESCRIPTION
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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)
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TARIFF DESCRIPTION
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| 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)
|
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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)
|
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5107
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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.
Optical
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. Benefit is applicable only to first consultation (0101) and follow-up consultation (0108) in the doctor’s room.
Medicine Formulary
Topaz only covers medication as specified in the Topaz and Topaz Plus HIV Medicine Formulary.
