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
|Treatment for injuries sustained in an accident||Yes|
|Removal of Appendix||Yes|
|Removal of tonsils and adenoids||Yes|
|Joint reconstruction and investigations||Yes|
|Surgical removal of wisdom teeth (hospital charge only)||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|
|Surgery on broken bones||Yes|
|Cosmetic surgery covered by Medicare||Yes|
|Cosmetic surgery (not covered by Medicare)||Excluded|
|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.
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|
(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
|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)
|Chiro/Osteo Initial visit – $40.00
Chiro/Osteo Subsequent visit – $30.00
Chiropractic X-rays – $100.00
Acupuncture visits- $25.00
|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
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
(Ante-natal classes limited to 10 classes per confinement)
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
|Podiatry||Initial visit – $44.00
Subsequent visit – $34.00
Podiatric devices – 80% of cost
* Benefits paid for registered clinical psychologists only.Hypnotherapy
* Benefits paid for registered clinical hypnotherapists only.
|Psychology visits – $75.00
Hypnotherapy visit – $50.00
* Benefits paid for registered DAA Dieticians only.
|Initial visit – $60.00
Subsequent visit – $40.00
|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
|Aids and Appliances
(contact the fund for items payable in this category)
|80% of charge
(after $20 copayment is made)
|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
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
- 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
- 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
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.