Phoenix’s Top Cover product combines comprehensive Top Hospital Cover with Phoenix’s highest level of Extras benefits, providing you with the highest level of cover available, for complete peace of mind.

 

Hospital cover inclusions

 

Treatments Covered
Treatment for injuries sustained in an accident Yes
Prosthesis Yes
Appendicitis treatment Yes
Removal of Appendix Yes
Removal of tonsils and adenoids Yes
Joint reconstruction and investigations Yes
Obesity Surgery Yes
Surgical removal of wisdom teeth (hospital charge only) Yes
Colonoscopy/Gastroscopy Yes
Pregnancy and birth related services Yes
Fertility treatment (e.g IVF & GIFT programs) Yes
Heart related services Yes
Major eye surgery (including cataract and eye lens services) Yes
Joint replacements Yes
Surgery on broken bones Yes
Renal dialysis Yes
Cosmetic surgery covered by Medicare Yes
Cosmetic surgery (not covered by Medicare) Excluded
Psychiatric services Yes
Rehabilitation Yes
Palliative care Yes
All other in-patient services where a Medicare benefit is payable Yes

 

For hospital services to which Phoenix Health Fund provides coverage, Top Cover provides coverage for:

 

  • Private and public hospital services nationwide (after the up-front excess has been paid) with access to an extensive range of quality services and approved programs in private hospitals which have an agreement with Phoenix Health Fund.
  • Public or Private Hospital bed – shared or private room (if available)
  • Same day patient fees
  • Theatre fees
  • Intensive care
  • Labour ward
  • In hospital pharmacy
  • Prosthesis (Commonwealth Government approved)
  • All other in-patient services where a Medicare benefit is payable (not listed as an exclusion in the hospital table above)

 

Additional costs you may incur are:

  • The amount the doctor charges above the Medicare schedule fee or “Access Gap” cover amount
  • some drugs, pharmacy items and non-PBS drugs for personal use or on discharge; and possibly
  • a co-payment for prostheses devices above the minimum benefit.
  • There are a small number of public hospitals that do not have agreements with us. In these cases a personal payment may apply. 

Nil Excess

Phoenix’s Top Cover policy does not have an excess. This means if you are admitted into hospital, an excess payment will not apply.

Medical Gap cover

Phoenix Health Fund, as a member of the Australian Health Service Alliance, has “Access Gap” arrangements with more than 15,000 doctors Australia-wide. These arrangements minimise or eliminate Members’ out-of-pocket expenses when our Members are treated as admitted hospital patients.

If your doctor participates in the “Access Gap” scheme, you will either have no out-of-pocket expenses to pay or will know exactly how much you will have to pay before treatment begins. Your doctor can bill Phoenix Health Fund direct, so in most cases you will not be required to lodge a claim with us, making it easier for you.

To check whether your doctor participates in “Access Gap”, use our Doctor Search facility, or ask your doctor.

Extras cover Inclusions

Unless otherwise stated, benefit limits apply per person per calendar year. Initial consultation benefits are paid only once per person per calendar year.

Benefit and limit amounts are effective from 1st April 2017.

Please also note that this page does not include the full detail of all services covered, and that sublimits apply for some services.  It is recommended that you contact the fund before your treatment to check exactly what you are covered for.

 

Treatment Benefit (for commonly claimed items) Annual Limit
General Dental 011 – Periodic oral examination – $36.50
114 – Scale & clean – $69.00
121 – Fluoride treatment – $24.00
No annual limit
Major Dental 615 – Full crown veneered – $875.00 $4,400
Sublimits include: $1,300 for inlays, onlays & Veneers, $1,600 for crowns/bridgework and $1,500 for implants
Endodontic 417 – Filling of one root canal – $170.00 No annual limit
Orthodontic Braces for upper/lower teeth – 80% of charge
Removal/ fitting of retainer  – 80% of charge
$2,400 life limit
Optical
(Excluded: Sunglasses, where no sight correction is needed)
Single vision lenses & frames – $220.00
Multi-focal lenses & frames – $310.00
Frame – $100.00
Single Vision Lenses – $120.00
Multifocal Lenses – $210.00
$310
Optical repairs 100% of charge $60
Artificial eyes 70% of charge $500
Non PBS Pharmaceuticals
(Excluded: contraceptives and items purchased over the counter)
Per eligible prescription – $70.00
(Paid after General PBS copayment has been paid)
$500
Chiropractic/Osteopathic

Acupuncture
(benefits paid for approved acupuncture associations only)

Chiro/Osteo Initial visit – $40.00
Chiro/Osteo Subsequent visit – $30.00
Chiropractic X-rays – $100.00
Acupuncture visits- $25.00
$450
Midwifery Ante-natal visits – $30.00
Post-natal visits – $50.00
Confinement delivery – $600.00
(benefit not payable if medical practitioner is required to intervene and take over the delivery)
10 visits per confinement
Home nursing Per visit – $15.00
Per day (over 6 hours) – $50.00
$500
Physiotherapy
Orthoptic Therapy
Speech Therapy
Occupational Therapy
Ante-natal classes (not related to Ante- natal visits)
Physiotherapy Initial visit – $50.00
Physiotherapy Subsequent visit – $37.00
Orthoptic Therapy Initial visit – $45.00
Orthoptic Therapy Subsequent visit – $44.00
Speech Therapy Initial visit – $85.00
Speech Therapy Subsequent visit – $45.00
Occupational Therapy Initial visit – $60.00
Occupational Therapy Subsequent visit – $40.00Ante-natal classes – $40.00
$800
(Ante-natal classes limited to 10 classes per confinement)
Natural therapies
Including Myotherapy, Homeopathy, Naturopathy and Chinese Herbal Medicine (consultation only)
Remedial massage* Benefits paid for approved associations only.  Click here for approved alternative therapy services.
Natural Therapies visits – $25.00
Remedial Massage visits – $25.00
$200
Podiatry Initial visit – $44.00
Subsequent visit – $34.00
Podiatric devices – 80% of cost
$400
Psychology
* Benefits paid for registered clinical psychologists only.Hypnotherapy
* Benefits paid for registered clinical hypnotherapists only.
Psychology visits – $75.00
Hypnotherapy visit – $50.00
$500
Dietetics
* Benefits paid for registered DAA Dieticians only.
Initial visit – $60.00
Subsequent visit – $40.00
$300
Healthy Lifestyle Program
* Approved Health Education, Health Screening, Health Management programs and Exercise Physiology only. Please contact the fund before you make a claim to check that the service provided is an approved program. Click here for more information
Exercise Physiology  visits – $30
All other services – 80% of charge
$150
Aids and Appliances
(contact the fund for items payable in this category)
80% of charge
(after $20 copayment is made)
$900
Travel and Accommodation
* Benefits payable where return distance is at least 200 kilometres.
Travel – benefit is equivalent of economy rail fare for distance travelled or 10c per kilometre. Combined benefit patient and attendant.
Overnight accommodation – per night, patient and attendant – $65
Travel limit – $120
Accommodation limit – $260

 

Ambulance Coverage

Phoenix Health Fund covers all medically necessary transport from a State Emergency Ambulance service. This also includes when an Ambulance is called to attend to you, but you do not subsequently need to be taken to hospital. Coverage is not offered when it is not medically necessary for you to be transported by an Ambulance.

Top Cover waiting periods

Hospital

  • 12 month waiting periods for pre-existing conditions
  • 12 month waiting periods for Pregnancy and birth related services
  • 12 month waiting periods for assisted reproductive services
  • 2 month waiting periods for all other hospital items

Extras

  • 2 month waits for General Dental and Endodontic dental procedures/claims
  • 12 month waits for Major Dental and Orthodontic dental procedures/claims
  • 6 month waits for Optical claims
  • 12 month waits for Hearing Aid claims
  • 2 month waits for all other extras items

Fund Rules

For the complete description of the Fund rules, relating this product, please refer to the General Information section on our website.

 

Please ensure you have read and retained the information relating to your policy of choice before applying for membership.