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Comparative Guide 2017

2 Bestmed Comparative Guide 2017 3Bestmed Comparative Guide 2017

Our focus is to provide superior healthcare to our members through the legendary Bestmed touch.

We are, after all, a medical scheme for members, by members. Over the years Bestmed has grown sustainably and has been able to build a reputable name in the industry. But Bestmed is still raising the bar in the medical aid industry to the point where we have grown our membership to reach the fourth overall position countrywide.

Bestmed belongs to its members. We deliver a service that gives personal attention to each query and enquiry that a member has. Members receive personal, individual and undivided attention in all their dealings with their chosen medical scheme.

It is Bestmed’s every intention to ensure that every member receives the quality service that they deserve.

As a self-administered scheme, Bestmed now has more than 95 000 principal members and provides healthcare benefits to over 200 000 lives. With our extensive experience and exceptional expertise, we can negotiate with our service providers to offer our members benefits and services that are, rand-for-rand, the best value compared to other large open medical schemes.

The right fit

To address our members’ desire for choice and flexibility, Bestmed has designed 13 healthcare options which are structured differently to suit various healthcare needs. We recognise that members’ healthcare needs will vary depending on age, marital status and different responsibilities and priorities. So, whether you essentially want to cover hospital costs or require a more comprehensive offering, covering all healthcare requirements, we have an option for you.

Our Beat, Pace and Pulse product offerings have been designed based on engagements and conversations with members over our many years of experience. After listening intently to their concerns, our healthcare experts have translated these insights into benefit options that are easy to understand and cater for all needs.

Focused on wellness

Your continued health and wellbeing is our primary concern. That is why we encourage all of our members to live a more preventive, meaningful and productive life through our wellness programme known as Health Check. We are here to assist you to become a better version of yourself through choosing a healthier lifestyle.

Our wellness philosophy is based on five basic wellness pillars. We encourage our members to:

Be Active: Incorporate exercise as part of your daily routine to promote positive changes.

Be Safe: Make responsible lifestyle choices to prevent adverse consequences.

Be Nutri-wise: Balanced nutrition is important to maintain a healthy body and mind.

Be Happy: Create and maintain a balance between work, life and home.

Be Fin-fit: Making informed financial decisions in life will ensure financial independence.

Personally Yours

The Corporate Partnership

Bestmed healthcare is based on sound partnerships. The way we engage with our corporate clients aims to establish and maintain long-term personal relationships, built on mutual trust and integrity. We further strive to provide affordable, excellent healthcare solutions, be accessible and provide personalised advice to all members and be flexible so processes are easy to follow.

About Bestmed

In line with this vision, Bestmed has adopted a three-pronged approach in order to deliver on its promise, which includes Corporate Wellness, a Client Service Programme, as well as Administration. Bestmed advisors are responsible for implementing these service programmes at employer organisations. Today, Bestmed services over 140 employer organisations, including large corporate businesses, some of South Africa’s biggest universities and a variety of parastatals.

Don’t worry, be appy!

Bestmed is proud to inform members that, thanks to continuous updates and development, the Bestmed app is now app-reciably better. Members are now able to get even more access to greater functionalities by simply downloading the Bestmed app onto their smartphones or tablets.

The completely user-friendly app will enable you to ease your interaction with Bestmed even further.

The Bestmed app now boasts a host of functionalities that include great features like a service provider search function, updating of your personal details and receiving your tax certificate directly to your cell phone. Chronic applications can also be submitted via our App.

Bestmed Provider Network

Bestmed has over the past five years, established several preferred and designated service provider networks with provider groups, an initiative designed to make sustainable, high-quality healthcare services available to our members at affordable premiums.

Member advantages of using Bestmed Provider Networks

Making use of the Bestmed provider networks has a number advantages to both providers and members. Some of the advantages include:

• Provider fees are set and managed as agreed.

• Quality of healthcare services are enhanced.

• Downstream costs are better managed.

• Providers are paid directly and on a weekly basis by the Scheme.

• No or minimum co-payments by the members depending on benefits available.

• A longer lasting medical savings account.

• Network lists, provider names and addresses are available on the website.

• A dedicated provider consultant service is available to the network providers.

Bestmed Designated Service Provider (DSP) Network for Prescribed Minimum Benefits (PMB).

The Specialist Network, which includes all the major specialist disciplines is a Designated Service Provider network. Currently there are 1 500 specialists on the network who are located across the country with rooms close to or in many of the general private hospitals. The coverage of this network also continues to grow with more and more providers joining each month. Bestmed members should therefore be able to easily access the specialists on the network.

From 1 May 2016 members are required to use a specialist on the DSP network for services related to their PMB conditions, and such service will be charged and paid at the agreed DSP rate.

Should a member voluntarily choose not to use a specialist from the DSP network for a PMB, the Scheme will only pay up to the Scheme rate, and any charges above this rate will be for the member’s account.


Below is a summary of the current Bestmed Provider networks:

Healthcare Provider Networks

Family practitioners

Family practitioner Pulse 1 network

Specialists

Pathology

Oncology

Pharmacies

Dentists

Dental network Pulse1 and Pulse2

Dental therapists

Dental technicians

Orthodontists

Ancillary Networks

Audiologists and speech therapists

Physiotherapists

Occupational therapists

Hearing aid acousticians

Counsellors

Midwives

Psychologists

Biokineticists

Dieticians

Product Supply Networks

Stents and pacemakers

Orthopaedic prosthesis

Oxygen supply

Sleep apnoea devices

Hearing aid devices

Service Networks

Drug and alcohol rehabilitation

Emergency services

Optometry services

Renal dialysis

Wound therapy

The Bestmed Networks apply to all options.

How do I access the detail and location of a network healthcare service provider?

Visit the Bestmed website and click on the links provided, or go directly to the provider page: http://providers.bestmed.co.za and follow these steps:

1. User chooses ‘Sign Up’

2. User is prompted to

- Indicate whether they are a scheme member or service provider

- thereafter enter member number (or practice number); and

- confirm either email address or cell number for validation. (i.e. member number + cell

number/e-mail address required to validate)

3. If validation succeeds, the user must register a password (which the user would need to

enter twice).

4. If validation fails, the user will be prompted to contact the call centre to update their details

5. Members and providers will only be able to access the site 24 hours after updating their

details, to allow the member file to be updated in the background.

6. Once logged in, use the search bar to search for discipline and town.

Bestmed Managed Care Programmes

The Managed Health Care Programmes have been developed to assist members by providing additional benefits to treat the following specific disease conditions with appropriate treatment, in a cost-effective manner. These programmes include: Oncology Care, HIV/AIDS Care, Dialysis Care, Alcohol and Substance Abuse Care, Wound Care, Stoma Care, Preventative Care, Maternity Care and Infant Care.

Oncology Care

Bestmed’s various benefit options have specified benefits that define the cover for cancer. Collectively these benefits are called oncology benefits.

Bestmed provides oncology benefits applying evidence-based medicine principles and considering affordability across the different benefit options. It has therefore appointed the Independent Clinical Oncology Network (ICON) for Beat4, Pace1, 2, 3, 4 and Pulse2 as DSP. Beat1, 2, 3 and Pulse1 members should make use of the state as DSP where available. Members on Pace3 and Pace4 have access to the enhanced option of ICON where it is clinically appropriate.

Members registered on the oncology programme qualify for cancer benefits. Members must forward a clinical summary and histology of their cancer, as set out by their treating doctor, to register on the programme. This must contain the history, ICD–10 codes, the clinical findings of the doctor as well as the test results confirming the cancer and the specific type of cancer.

HIV/AIDS Care

Acquired immunodeficiency syndrome (AIDS) is a chronic, potentially life-threatening condition caused by the human immunodeficiency virus (HIV). By damaging your immune system, this virus interferes with your body’s ability to fight the organisms that cause disease.

HIV/AIDS is a sexually transmitted infection. It can also be spread by contact with infected blood or from mother to child during pregnancy, childbirth or breastfeeding. Without medicine, it may take years before HIV weakens your immune system to the point that you have full blown AIDS.

There is currently no cure for HIV/AIDS, but there is medicine available that can dramatically slow down the progression of the disease.

To qualify for benefits, a member or dependant must register on the HIV/AIDS programme. A member must forward a clinical summary that has been obtained from the treating doctor to the DSP as appointed by the Scheme.. This summary must contain the relevant history, clinical findings, results of the HIV/AIDS diagnostic test as well as all the CD4 and viral load test results. Any additional results that have a bearing on the clinical picture or the impact the disease has on the patient, must be forwarded. Examples of such tests include full blood count, liver function tests and specimens sent for microscopy.

Bestmed has the widest hospital network range in South Africa. 247 hospitals and clinics in total!

Being self-administered means that we do not use member’s contributions to pay a company to do our administration. This means that more of your money goes into giving you more benefits.


The programme also makes provision for blood tests to follow the course of the disease and to measure the response to treatment, medicine and anti–retrovirals, as well as medicine specifically used to fight the virus. The treatment programme covered by the Scheme is based on the HIV/AIDS funding guideline and approved treatment depends on the clinical parameters of each individual. The stage of the disease and the results of blood tests determine what treatment will be covered and how the individual must be followed up. Cover is also provided for mother–to–child transmission in pregnancy and as post–exposure prophylaxis. Visit the website to view the Designated Service Provider for case management and dispensing anti-retroviral medication.

Dialysis Care

Members who require chronic dialysis for end-stage renal disease can register on the dialysis programme. Depending on clinical and other parameters, the Scheme will consider funding for peritoneal or haemodialysis. Certain medicines that are used in end-stage renal disease are only covered when the Scheme funding guidelines are met. Bestmed has appointed National Renal Care (NRC) as Designated Service Provider (DSP) for renal dialysis services for its members on all the benefit options.

Only members registered on the dialysis programme qualify for additional benefits. In order to be registered on the programme, patients must obtain a clinical summary of their condition as set out by their treating doctor. This must contain the history, ICD-10 codes and clinical findings of the doctor as well as the test results and details on any associated disease, e.g. diabetes.

Alcohol and Substance Abuse Care

Bestmed has contracted various designated service providers (DSPs) to provide rehabilitation for alcohol and substance abuse. Please note that this benefit is subject to pre-authorisation and will be funded up to a maximum limit or 21 days, or whichever is depleted first.

Wound Care

Specialised wound care therapy, including dressings and negative-pressure wound therapy (NPWT) treatment and related nursing services are included in Bestmed’s Provider Network.

Stoma Care

Bestmed has partnered with a supplier for the supply and distribution of stoma and incontinence care products. Bestmed members who are registered on Stoma Care receive the following value-added benefits:

• Patients are assisted to obtain the relevant Scheme authorisation for their stoma products.

• Patients are provided with direct contact details for the supplier’s business unit to address all their product-related enquiries.

• Patients are provided with a quoting and product sourcing service of the most affordable and cost-effective products as not all stoma and incontinence care needs of patients are covered in full by the medical Scheme.

• Direct submissions of claims to Bestmed to ensure that they do not have to pay cash up front and claim back from the Scheme.

Preventative Care

At Bestmed we encourage our members to actively pursue a healthier and more active lifestyle to encourage better health.

In line with this philosophy we have developed preventative care that entitles you, the member, to undergo a number of screenings, preventative tests and vaccines to encourage better health.

Preventative care is important in making sure you detect medical conditions early and we can ensure the best care for you in this regard. Bestmed offers preventative care that covers a number of benefits from the Scheme’s risk benefit, and not your savings. General and option-specific exclusions may apply to the various options. Please refer to www.bestmed.co.za for more details.

Flu vaccines: All members are eligible, and annually receive a letter to remind them of this preventative care benefit when flu vaccines become available. By making use of preferred provider pharmacies for flu vaccines, members will have minimum or no co-payments.

Pneumonia vaccines: Every year Bestmed identifies high-risk members, who receive a pneumonia letter to advise them that they are eligible for their pneumonia vaccination. Special requests from doctors on behalf of members to receive these vaccinations are evaluated and clinically reviewed for authorisation.

Paediatric immunisations: Bestmed reimburses vaccines for children as listed on the Department of Health vaccine schedule on all Bestmed options, except for Beat1 and Beat2.

Back and neck preoperational assessment: The Bestmed Back and Neck programme is based on the Documentation Based Care (DBC) for back and neck rehabilitation and treatment programme that has been developed in Finland over the past 20 years.

The back and neck programme is completely evidence and outcomes based with a success rate in excess of 85% after a six-week period of rehabilitation and treatment.

DBC principles applied are those of analysing, correcting and maintaining correct body posture as well as stabilisation of the spine.

All members are eligible for this benefit. For a member to register on the programme he/she needs to visit a DBC clinic and have an assessment done by the doctor who will then motivate if the patient qualifies for this rehabilitation programme. The member can thereafter send the application to Bestmed for authorisation. It includes twelve sessions during a six-week period and an evaluation by a Documented Based Care (DBC) clinic.

Haemophilus influenzae Type B vaccine (HIB titre): This vaccine is administered in the prevention of illnesses that are caused by this bacterium – most commonly bacteremia, pneumonia, epiglottitis, bacterial meningitis.

Human papillomavirus vaccine (HPV): The HPV vaccination is administered to assist in the prevention of cervical cancer and anal cancer. This benefit is available to all females between nine and twenty-six years of age. Please note that protocols and general and option-specific exclusions may apply.

Female contraceptives: All females of child-bearing age qualify for female contraceptives to the value of R1 800 per family per year.

Preventative dentistry: This benefit includes a general full-mouth examination by a general dentist, full-mouth inter-oral radiographs, scaling and polishing, fissure sealing and space maintainers for all members. General and option-specific exclusions may apply.

Mammogram: All females 40 years and older qualify for a mammogram. Please note that protocols and general and option-specific exclusions may apply. Please refer to www.bestmed.co.za for more details.

Pap smear: All females 18 years and older qualify for a pap smear. Please note that protocols and general and option-specific exclusions may apply. Please refer to www.bestmed.co.za for more details.

PSA screening: Prostate-specific antigen (PSA) blood test is a cancer screening test. PSA is a substance made by cells in the prostate gland (both normal cells and cancer cells). PSA is mostly found in semen, but a small amount is also found in the blood. Most healthy men have levels under four nanograms per millilitre (ng/mL) of blood. All males older than 50 qualify for a PSA test. Please note that protocols and general and option-specific exclusions may apply. Please refer to www.bestmed.co.za for more details.

One dietician counselling session: One dietician counselling session per family per year is covered by Bestmed. Please note that protocols and general and option-specific exclusions may apply. Please refer to www.bestmed.co.za for more details.

Health Check: This programme is available to all Bestmed members, once a year, for free biometric screenings. Available to all beneficiaries over the age of 18.

These screenings consist of a detailed questionnaire that you may obtain from the Bestmed website. Print the questionnaire and complete it. Upon completion please take it to a Dis-Chem, Clicks, Sparkport, Scriptsavers (Van Heerden/Klinicare pharmacies) to have your Health Check

8 Bestmed Comparative Guide 2017

Beat

Beat

The Beat option range offers flexible hospital benefits with limited savings on some options to pay for out-of-hospital expenses. This range is ideal for the young, active and starting out. Beat1, 2 and 3 also

offer you the decision to lower your monthly contribution in the form of a Network option.

completed. The following information will be obtained from you: your height and weight, while your blood pressure and rapid cholesterol as well as glucose levels will be tested. Once finalised, please send it back to Bestmed. Your results will be loaded onto the system and you will receive a personal report about your health status.

For more information about the Health Check programme please send an e-mail to: [email protected] or send a fax to: 012 472 6787.

Maternity Care

With so many things to juggle, the Maternity Care programme is here to help moms and dads through their entire pregnancy and the first two years with a new little one in the home. At Bestmed, we want you to enjoy this entire experience and feel comfortable knowing that we are here for you.

Registering on this programme will give you the following support and benefits:

• A 24-hour professional medical advice line you can call with any queries, no matter how small.

• Weekly e-mails packed with convenient information about your pregnancy, your baby’s development, how to deal with unpleasant pregnancy symptoms and useful hints.

• Dads won’t be left out as they will also receive e-mails every second week to inform them about the baby’s development and Mom’s progress.

• To make sure your pregnancy starts right, you will receive a welcome pack containing an informative pregnancy book to guide you through the stages as well as discount vouchers for various baby items.

• In your second month after registration, we will send you a useful baby bag packed with products to use after your baby’s birth.

You are able to register on the Maternity Care programme simply by sending an e-mail to [email protected] or you can call us on 086 111 1936.

* Please note that you may only register on the Maternity Care programme after the 12th week of pregnancy.

Infant Care

A baby is a reason to celebrate and that is why Bestmed has an Infant Care programme to help new moms through the first months, offering support and sound advice.

At Bestmed we realise how unfamiliar and uncertain life with a newborn can prove to be. Infant Care has been specifically designed to guide you through this time and offer you benefits to make the arrival of your new baby even more special.

We understand that the first two years, and especially the initial phase, can be an incredibly daunting time for any new parent and that is why we have developed a programme that will assist with any immunisation information, lactation consultations and any other information pertaining to the medical care of your baby.

We will also offer you a range of added benefits to make life just a little sweeter and a little more special.

Bestmed is the only Scheme that covers midwife-assisted births at 100% of Scheme tariff, on all options.

It’s free to register on the Bestmed Maternity and Infant Care programmes.

11Bestmed Comparative Guide 201710 Bestmed Comparative Guide 2016

Beat1 Beat2 Beat3 Beat4In-hospital services are paid from Scheme risk benefit and out-of-hospital services will be for the member’s own account. Some preventative care services are

available from Scheme risk benefit.

In-hospital services are paid from Scheme risk benefit and out-of-

hospital services will be paid from the savings account. Some preventative

care services are available from Scheme risk benefit.

In-hospital services are paid from Scheme risk benefit. Some day-to-day

services are paid from the Scheme risk benefit and other services will be paid from the savings account.

Some preventative care services are available from Scheme risk benefit.

In-hospital services are paid from Scheme risk benefit. Some out-

of-hospital services are paid from the annual savings first and, once

depleted, will be paid from the day-to-day benefit. Once the day-

to-day benefit is depleted, services can be paid from the available vested

savings. Some preventative care services are available from Scheme

risk benefit.

Method of Scheme benefit payment

Beat1 Beat2 Beat3 Beat4Accommodation (hospital stay) and theatre fees

100% Scheme tariff. DSP specialist network applicable if the discounted Network option is chosen.

100% Scheme tariff.

Take-home medicine 100% Scheme tariff. Limited to 7 days’ medicine.

Treatment in mental health clinics 100% Scheme tariff. Limited to 21 days per beneficiary.

Treatment of chemical and substance abuse

100% Scheme tariff. Limited to 21 days or R25 200 per beneficiary. Subject to network facilities.

Consultations and procedures 100% Scheme tariff. DSP specialist network applicable if the discounted Network option is chosen.

100% Scheme tariff.

Surgical procedures and anaesthetics 100% Scheme tariff. 100% Scheme tariff.

Organ transplants 100% Scheme tariff. (Only PMBs).

Major medical maxillo-facial surgery strictly related to certain conditions

No benefit (PMBs only at DSP day hospitals) 100% Scheme tariff. Limited to R10 100 per

family.

100% Scheme tariff. Limited to R10 300

per family.

Dental and oral surgery No benefit.(PMBs only at DSP day hospitals) Limited to R6 300 per family.

Limited to R7 900 per family.

In-hospital benefits

Beat Network Range■■ For members on the Beat Network option, Bestmed offers members a choice of network hospitals for the in-hospital benefits.

■■ Should a member voluntarily choose not to make use of a hospital forming part of a hospital network for the Beat Network benefit option, a maximum co-payment of R10 000 shall apply to the voluntary use of a non-designated service provider.

■■ Non-network option refers to the standard Beat benefit option. Network refers to the Beat Networks.

Note: Benefits mentioned below are subject to pre-authorisation and clinical protocols.

In-hospital benefits (continued)

Beat1 Beat2 Beat3 Beat4Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)

100% Scheme tariff. Limited to R61 550 per family.

100% Scheme tariff. Limited to R62 200 per

family.


per family.

Prosthesis – Internal

Note: Sub-limit subject to the above prosthesis limit.

*Functional: Items utilised towards treating or supporting a bodily function

Sub-limits per beneficiary:■■ Functional limited to R11 000■■ Vascular R24 500■■ Pacemaker (dual chamber) R33 550■■ Endovascular and catheter base procedures - no benefit■■ Spinal R24 500■■ Artificial disk - no benefit■■ Drug-eluting stents - no benefit■■ Mesh R8 650■■ Gynaecology/urology R7 050■■ Lens implants R5 350 per lens

Sub-limits per beneficiary:■■ Functional limited to

R11 000 ■■ Vascular R24 700■■ Pacemaker (dual

chamber) R33 550■■ Endovascular and

catheter base procedures - no benefit

■■ Spinal R24 700■■ Artificial disk - no

benefit■■ Drug-eluting stents - no

benefit■■ Mesh R8 650■■ Gynaecology/urology

R7 150■■ Lens implants R5 350

per lens


R13 200■■ Vascular R26 200■■ Pacemaker (dual


catheter base procedures - no benefit

■■ Spinal R26 200■■ Artificial disk -

no benefit■■ Drug-eluting stents

R14 750■■ Mesh R9 700■■ Gynaecology/Urology


per lens

Prosthesis – External No benefit No benefit Limited to R18 250 per family.

Exclusions (Prosthesis sub-limit subject to preferred provider, otherwise limits and co-payments apply)

Joint replacement surgery. (Except for PMBs). PMBs subject to prosthesis limits:■■ Hip replacement and other major joints R25 850■■ Knee replacement R31 850■■ Other minor joints R9 900

Joint replacement surgery. (Except for PMBs). PMBs subject to prosthesis limits:■■ Hip replacement and

other major joints R26 050

■■ Knee replacement R32 200

■■ Other minor joints R9 900

Joint replacement surgery (except for PMBs) PMBs subject to prosthesis limits: ■■ Hip replacement and

other major joints R26 950

■■ Knee replacement R35 800

■■ Other minor joints R11 000

Orthopaedic and medical appliances 100% Scheme tariff.

Pathology 100% Scheme tariff.

Diagnostic imaging 100% Scheme tariff.

Specialised diagnostic imaging 100% Scheme tariff. Subject to co-payments. 100% Scheme tariff.

Oncology PMB Only (DSP: State hospitals where available) 100% Scheme tariff. Oncology programme.

Peritoneal dialysis and haemodialysis

No benefit. PMBs only at DSPs. 100% Scheme tariff. Subject to pre-authorisation

Confinements 100% Scheme tariff.

Refractive surgery No benefit. 100% Scheme tariff. Subject to pre-

authorisation and protocols. Limited to R6 500 per eye.

100% Scheme tariff. Subject to pre-authorisation

and protocols. Limited to R7 350 per eye.

Midwife-assisted births 100% Scheme tariff.

Supplementary services 100% Scheme tariff.

Alternatives to hospitalisation 100% Scheme tariff.

Emergency evacuation 100% Scheme tariff. Pre-authorised and rendered by ER24.

Co-payments Co-payment of R3 000 on all endoscopic investigations and specialised diagnostic imaging if done in a private

hospital. Any other facility, no co-payment.

Co-payment of R3 000 on all endoscopic investigations if done in a private hospital. Any other

facility, no co-payment.

Not applicable.Know about an in-hospital medical procedure you may need? Save money by getting pre-authorisation before you go in.

The Non-Network option provides you with access to any hospital of your choice. This is the standard option.

The Network option provides you with a list of designated hospitals for you to use and also saves on your monthly contribution.

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Out-of-hospital benefits

Beat1 Beat2 Beat3 Beat4Overall day-to-day limit Not applicable. M = R10 000, M1+ = R20 000.

GP and specialist consultations No benefit. Savings account. Savings first. Limited to M = R2 550,

M1+ = R4 550. (Subject to overall day-to-day limit)

Basic and specialised dentistry No benefit. Basic: Preventative benefit or savings account. Specialised: Savings account.

Orthodontic: Subject to pre-authorisation.

Savings first. Limited to M = R4 300,

M1+ = R8 650. (Subject to overall day-to-day limit) Orthodontics are

subject to pre-authorisation.

Medical aids, apparatus and appliances including wheelchairs and hearing aids

No benefit. Savings account. Savings first. 100% Scheme tariff. Limited to R9 000 per

family. (Subject to overall day-to-day limit)

Supplementary services No benefit. Savings account. Savings first. Limited to M = R3 900,


Wound care benefit (incl. dressings and negative pressure wound therapy (NPWT) treatment and related nursing services - out-of-hospital)

100% Scheme tariff. Limited to R 2 750 per family.

Savings first. 100% Scheme tariff. Limited to R3 900 per


Optometry benefit (PPN capitation provider)

No benefit. Savings account. ■■ Consultation R350■■ Frame R550

■− Single-vision lenses R165 OR

■− Bifocal lenses R360 OR

■− Multifocal lenses R660 ■■ Contact lenses R1 000

■■ Consultation R350■■ Frame R550

■− Single-vision lenses R165 OR

■− Bifocal lenses R360 OR

■− Multifocal lenses R660 ■■ Contact lenses R1 210

Diagnostic imaging and pathology

No benefit. Savings account. Savings first. Limited to M = R2 550,


Specialised diagnostic imaging 100% Scheme tariff.Limited to R4 200 per family.

100% Scheme tariff. Limited to R8 750 per

family.

100% Scheme tariff.Limited to R13 200 per family.

Oncology PMB only Oncology programme.

Maternity benefits No benefit. Savings account. 100% Scheme tariff. 2 sonars and up to 12 antenatal consultations.

Rehabilitation services after trauma

No benefit. Savings account. Vested savings.

Note: Benefits mentioned below may be subject to pre-authorisation and clinical protocols. All payments are made at Scheme tariff.

Beat1 Beat2 Beat3 Beat4CDL & PMB chronic medicine 100% Scheme tariff. Co-payment of 40% for non-formulary medicine. 100% Scheme tariff.

Co-payment of 30% for non-formulary medicine.

Non-CDL chronic medicine No benefit. 5 conditions.

75% Scheme tariff. Limited to M = R2 700, M1+ = R5 450.


8 conditions.



Biologicals and other high-cost medicine

No benefit.

Acute medicine No benefit. Savings account. Savings first. Limited to M = R2 250, M1+ = R4 550.

(Subject to overall day-to-day limit)

Over-the-counter (OTC) medicine No benefit. Savings account. Paid from savings. Limited to R525.

MedicineNote: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP). Approved CDL, PMB and non-CDL chronic medicine costs will pay from the non-CDL chronic medicine limit first. Once the limit is depleted, CDL and PMB chronic medicine will continue to pay unlimited from Scheme risk. Note: Refer to the Chronic Conditions List at the back of the Comparative Guide.

Beat1 Beat2 Beat3 Beat4Preventative care benefits

Note: Refer to Scheme rules for funding criteria applicable to each preventative care benefit.

■■ Flu vaccines■■ Pneumonia programme■■ Female contraceptives -

R1 800 per family per annum

■■ DBC programme■■ Biometric screenings

(Health Check)■■ Pap smear – ages 18 and

above, every 24 months.

■■ Flu vaccines■■ Pneumonia vaccines■■ Female contraceptives -

R 1 800 per family per annum

■■ DBC programme■■ Preventative dentistry

(incl. gloves and sterile equipment)

■■ Biometric screenings (Health Check)

■■ Pap smear – ages 18 and above, every 24 months.

■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations■■ Female contraceptives -





■■ Pap smear – ages 18 and above, every 24 months.

■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations■■ Female contraceptives -




■■ Haemophilus influenzae Type B vaccine (HIB)

■■ Mammogram■■ HPV vaccinations■■ PSA Screening for ages

50 years and above, every 24 months.


■■ Pap smear – ages 18 and above, every 24 months

■■ One dietician counselling session per family per annum.

Disclaimer on exclusions: General and option-specific exclusions apply. Please refer to www.bestmed.co.za for more details.

Preventative care benefitsNote: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP).

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ContributionsBeat1 Beat2 Beat3 Beat4

Non-Network (NN)/ Network (N)

NN N NN N NN N NN

PRINCIPAL MEMBER

Risk R1 257 R1 131 R1 290 R1 161 R1 958 R1 762 R3 075

Savings R0 R0 R264 R238 R401 R361 R543

Total R1 257 R1 131 R1 554 R1 399 R2 359 R2 123 R3 618

ADULT DEPENDANT

Risk R976 R879 R1 003 R902 R1 391 R1 252 R2 540

Savings R0 R0 R205 R185 R285 R257 R448

Total R976 R879 R1 208 R1 087 R1 676 R1 509 R2 988

CHILD DEPENDANT

Risk R529 R476 R544 R489 R756 R681 R761

Savings R0 R0 R111 R100 R155 R139 R134

Total R529 R476 R655 R589 R911 R820 R895

Maximum contribution child dependants*

4

Recognition of a child dependant

Under 21, unless a registered student.

* You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.

AbbreviationsCDL = Chronic Disease List; DBC = Documentation Based Care (back rehabilitation programme); DSP = Designated Service Provider; GP = General Practitioner or Doctor; Health Check = Biometric Screenings; HIB = Haemophilus influenzae Type B vaccine; HPV = Human Papilloma Virus; M = Member; M1+ = Member and family; MRP = Mediscor Reference Price; PMB = Prescribed Minimum Benefits; PPN = Preferred Provider Negotiators; PSA = Prostate Specific Antigen.

For a more detailed overview of your benefit option and to receive a membership guide please contact [email protected] Disclaimer: All the 2017 product information appearing in this brochure is provided without a representation or warranty whatsoever, whether expressed or implied and no liability pertaining thereto will attach to Bestmed Medical Scheme. All information regarding the 2017 benefit options and accompanying services including information in respect of the terms and conditions or any other matters is subject to prior approval of the Council for Medical Schemes (CMS) and may change without notice having due regard to the CMS’s further advices. Bestmed accepts no liability whatsoever for any loss whether direct, indirect or consequential arising from information provided in this brochure or any actions and/or transactions resulting therefrom. Please visit www.bestmed.co.za for the complete liability and responsibility disclaimer for Bestmed Medical Scheme as well as our terms and conditions.

Bea

t

Pace

The Pace range offers more comprehensive benefits on both in-hospital and out-of-hospital. These options all have additional savings accounts to cover extensive out-of-hospital expenses. This range is ideal for families and those seeking comprehensive cover.

Pace

17Bestmed Comparative Guide 2017

Pace


Pace1 Pace2 Pace3 Pace4In-hospital services are paid from Scheme risk benefit. Some out-of-hospital services are paid from the annual savings first and once depleted will be paid from the day-to-day benefit. Once the day-to-day benefit is depleted, services can be paid from the available vested savings. Some preventative care

services are available from Scheme risk benefit.

In-hospital services, out-of-hospital services and preventative care services are paid from Scheme

risk benefit. Once out-of-hospital risk benefits are depleted, further claims will be paid from savings.


Pace1 Pace2 Pace3 Pace4Accommodation (hospital stay) and theatre fees

100% Scheme tariff.

Take-home medicine 100% Scheme tariff. Limited to 7 days’ medicine.

Treatment in mental health clinics

100% Scheme tariff. Limited to 21 days per beneficiary.

Treatment of chemical and substance abuse

100% Scheme tariff.Limited to 21 days or R25 200 per beneficiary. Subject to network facilities.

Consultations and procedures 100% Scheme tariff.

Surgical procedures and anaesthetics

100% Scheme tariff.

Organ transplants 100% Scheme tariff. (Only PMBs)

100% Scheme tariff.



per family.

100% Scheme tariff.

Dental and oral surgery Limited to R6 300 per family.




Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)


per family.


per family.


per family.


per family.


Note: Sub-limit subject to the above prosthesis limit.



R12 650■■ Vascular R25 650 ■■ Pacemaker (dual


cathether base procedures - no benefit

■■ Spinal R25 650■■ Artificial disk - no benefit■■ Drug-eluting stents -

no benefit■■ Mesh R9 650■■ Gynaecology/urology


per lens



chamber) R48 850■■ Spinal R33 900■■ Artificial disk R14 850■■ Drug-eluting stents

R14 850■■ Mesh R14 850■■ Gynaecology/urology


per lens■■ Joint replacements:

■− Hip replacement and other major joints R40 700

■− Knee replacement R47 250

■− Minor joints R17 550



chamber) R48 850■■ Spinal R34 000■■ Artificial disk R14 850■■ Drug-eluting stents








R15 400■■ Vascular R38 900■■ Pacemaker (dual chamber)

R48 850■■ Spinal R38 900■■ Artificial disk R17 450■■ Drug-eluting stents







In-hospital benefitsAll benefits below are subject to pre-authorisation and clinical protocols.


Pace1 Pace2 Pace3 Pace4

Prosthesis – External Limited to R17 950 per family.





Joint replacement surgery (except for PMBs). PMBs subject to prosthesis limits:■■ Hip replacement and

other major joints R26 200■■ Knee replacement R34 750■■ Other minor joints R10 800

Not applicable.

Orthopaedic and medical appliances

100% Scheme tariff.



Specialised diagnostic imaging 100% Scheme tariff.

Oncology Oncology programme. PMBs only at DSP.

Oncology programme. 100% Scheme tariff.

Peritoneal dialysis and haemodialysis

PMBs only at DSPs. 100% Scheme tariff.


Refractive surgery 100% Scheme tariff. Limited to R7 000 per eye.


per eye.

100% Scheme tariff. Limited to R7 900 per eye.

Midwife-assisted births 100% Scheme tariff.




Co-payments Not applicable.

Generic options of medicine are always available at a lower cost than the original brand and are just as effective. Bestmed recommends using these generic alternatives as using the more expensive can incur additional costs.

Did you know that Bestmed’s Pace option range does not have a self-payment or co-payment gap.

Pace


Pace

Pace1 Pace2 Pace3 Pace4Overall day-to-day limit M = R8 500,

M1+ = R17 000.M = R12 000,

M1+ = R24 000. M = R15 000,

M1+ = R31 000.M = R28 000,

M1+ = R45 100.

GP and specialist consultations



Savings first.Limited to M = R3 450,


Savings first. 100% Scheme tariff.

M = R3 450, M1+ = R7 150. (Subject to overall day-to-

day limit)

Limited to M = R4 400, M1+ = R7 150. (Subject to

overall day-to-day limit)

Basic and specialised dentistry

Savings first. Basic: Preventative benefit or

savings account. Limit once savings exceeded. Specialised: Savings account

then limit.Orthodontic: Subject to

pre-authorisation.Limited to M = R3 150,




then limit.Orthodontic: Subject to

pre-authorisation.Limited to M = R5 300,




then limit. Orthodontic: Subject to

pre-authorisation. 100% Scheme tariff. Limited

to M = R5 700, M1+ = R10 600. (Subject to


Limited to M = R9 500,M1+ = R16 100. (Subject to

overall day-to-day limit)Orthodontics are subject to

pre-authorisation.





family. (Subject to overall day-to-day limit).

Limit on wheelchairs of R11 050 per family per

48 months.

Limit on hearing aids of R22 450 per beneficiary per

24 months.


family. (Subject to overall day-to-day limit).


48 months.


24 months.

100% Scheme tariff. Limited to R8 150 per family. (Subject

to overall day-to-day limit).


48 months.


24 months.

Supplementary services Savings first.Limited to M = R3 450,


Savings first.Limited to M = R4 300,




Limited to M = R4 400,M1+ = R8 650. (Subject to









Limited to R10 800 per family. (Subject to overall

day-to-day limit)

Optometry benefit (PPN capitation provider)

■■ Consultation R350■■ Frame R550 AND

■− Single vision lenses R165 OR

■− Bifocal lenses R360 OR■− Multifocal lenses R660

■■ Contact lenses R1 000







■− Bifocal lenses R360 OR ■− Multifocal lenses R660







Savings first. 100% Scheme tariff. Limited to M = R2 550,







(Subject to overall day-today limit)

Maternity benefits 100% Scheme tariff. 2 sonars and up to 12 antenatal consultations.

Specialised diagnostic imaging


MRI/CT scans: Maximum of three scans per beneficiary. PET scan: One scan per beneficiary. 100% Scheme tariff.

Rehabilitation services after trauma

Vested savings. 100% Scheme tariff.

Oncology Oncology programme. (PMB only)

Oncology programme. 100% Scheme tariff.

Out-of-hospital benefitsBenefits mentioned below may be subject to pre-authorisation and clinical protocols. All payments are made at Scheme tariff.

Pace1 Pace2 Pace3 Pace4CDL & PMB chronic medicine

100% Scheme tariff.Co-payment of 35% for non-formulary medicine.




Non-CDL chronic medicine

7 conditions. 85% Scheme tariff.

Limited to M = R5 200, M1+ = R10 450.



Limited to M = R7 150, M1+ = R14 300.



Limited to M = R11 500, M1+ = R23 000.



Limited to M = R15 550, M1+ = R31 150.



No benefit. Limited to R129 700 per beneficiary.

Limited to R259 350 per beneficiary.

Limited to R383 700 per beneficiary.

Acute medicine Savings first. Limited to M = R1 850,

M1+ = R3 800. (Subject to overall day-to-day limit).





Limited to M = R6 950, M1+ = R10 800.

(10% co-payment) (Subject to overall day-to-day limit).

Over-the-counter (OTC) medicine

Paid from savings. Limited to R525. Savings account.

MedicineNote: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP). Approved CDL, PMB and non-CDL chronic medicine costs will pay from the non-CDL chronic medicine limit first. Once the limit is depleted, CDL and PMB chronic medicine will continue to pay unlimited from Scheme risk. Note: Refer to the Chronic Conditions List at the back of the Comparative Guide.

Preventative care benefits

Pace1 Pace2 Pace3 Pace4Preventative care


■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations■■ Female contraceptives –





■■ Mammogram■■ HPV vaccines■■ Biometric screenings

(Health Check)■■ Pap smear – age 18 and

above, every 24 months.

■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations■■ Female contraceptives –





■■ Mammogram■■ PSA screening – ages

50 and above, every 24 months

■■ HPV vaccines■■ Biometric screenings

(Health Check)■■ Pap smear – age 18 and

above, every 24 months■■ One dietician counselling

session per family.

■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations■■ Female contraceptives – R1 800 per family per annum ■■ DBC programme■■ Preventative dentistry (incl. gloves and sterile equipment)■■ Haemophilus influenzae Type B vaccine (HIB)■■ Mammogram■■ PSA screening - ages 50 and above, every 24 months■■ HPV vaccines■■ Bone densitometry■■ Biometric screenings (Health Check)■■ Pap smear – ages 18 and above, every 24 months■■ One dietician counselling session per family.

Disclaimer on exclusions: General and option specific exclusions apply. Please refer to www.bestmed.co.za for more details.

Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP).

Pace


AbbreviationsDBC = Documentation Based Care (Back Rehabilitation Programme); DSP = Designated Service Provider; GP = General Practitioner or Doctor; Health Check = Biometric Screenings; HIB = Haemophilus influenzae Type B vaccine; HPV = Human Papilloma Virus; M = Member; M1+ = Member and family; MRI/CT scans = Magnetic Resonance Imaging/Computed Tomography scans; MRP = Mediscor Reference Price; NP = Network Provider; PET scan = Positron Emission Tomography scan; PMB = Prescribed Minimum Benefits; PPN = Preferred Provider Negotiators; PSA = Prostate Specific Antigen.

Pace1 Pace2 Pace3 Pace4Income level N/A ■< R98 500 p.a. > R98 500 p.a. N/A

PRINCIPAL MEMBER

Risk R2 444 R3 668 R3 607 R4 332 R5 913

Savings R611 R647 R636 R765 R183

Total R3 055 R4 315 R4 243 R5 097 R6 096

ADULT DEPENDANT

Risk R1 716 R3 596 R2 885 R3 456 R5 913

Savings R429 R635 R509 R610 R183

Total R2145 R4 231 R3 394 R4 066 R6 096

CHILD DEPENDANT

Risk R617 R808 R669 R725 R1 385

Savings R154 R143 R118 R128 R43

Total R771 R951 R787 R853 R1 428

Maximum contribution child dependant*

4


Under 21, unless a registered student.

Contributions

*You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.

Bestmed can negotiate with service providers to offer members benefits and services that offer, on a Rand-for-Rand basis, the best value compared to other large open medical schemes.

Visit the Bestmed website to use our Chat Now functionality enabling you to chat directly to one of our friendly consultants.


Pulse

The Pulse option range is a network designated option range only. This option range provides in-hospital and out-of-hospital benefits at designated network providers only.

Pace

Pulse


Pulse

Pulse1 Pulse2In-hospital services are paid from Scheme risk benefit.

Some preventative care services are available from Scheme risk benefit.Some out-of-hospital services are paid from Scheme risk benefits.

In-hospital services are paid from Scheme risk benefit. Some day-to-day services and preventative care services are available from

Scheme risk benefit. Some out-of-hospital services are paid from Scheme risk benefits.


Pulse1 Pulse2Accommodation (hospital stay) and theatre fees 100% Scheme tariff at a Netcare DSP hospital.

Take-home medicine 100% Scheme tariff. Limited to 3 days’ medicine. 100% Scheme tariff. Limited to 7 days’ medicine.

Treatment in mental health clinics 100% Scheme tariff. Limited to 21 days per beneficiary.

Treatment of chemical and substance abuse 100% Scheme tariff. (only PMBs)Subject to network facilities. Limited to 21 days

per beneficiary.

100% Scheme tariff.Limited to 21 days or R25 200 per beneficiary.

Subject to network facilities.

Consultations and procedures 100% Scheme tariff.

Surgical procedures and anaesthetics 100% Scheme tariff. Excluded from benefits: functional nasal surgery,

surgery for medical conditions e.g. Epilepsy, Parkinson’s disease etc., and procedures where

stimulators are used.

100% Scheme tariff.

Organ transplants 100% Scheme tariff. (Only PMBs)


No benefit. 100% Scheme tariff.

Dental and oral surgery No benefit. 100% Scheme tariff.

Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)




Note: Sub-limit subject to the above prosthesis limit


Sub-limits per beneficiary:■■ Functional R8 800■■ Vascular R20 500■■ Pacemaker (dual chamber) R33 550■■ Endovascular and catheter based procedures -

no benefit■■ Spinal R20 500■■ Artificial disk - no benefit■■ Drug-eluting stents - no benefit■■ Mesh R7 500■■ Gynaecology/urology R6 200■■ Lens implants R4 300 per lens

Sub-limits per beneficiary:■■ Functional R13 750■■ Vascular R32 050■■ Pacemaker (dual chamber) R43 400 ■■ Spinal R32 050■■ Artificial disk R14 100■■ Drug-eluting stents R14 100■■ Mesh R14 100■■ Gynaecology/urology R10 450■■ Lens implants R8 950 per lens■■ Joint replacements:

■− Hip replacement and other major joints R38 300■− Knee replacement R44 750■− Minor joints R16 650

Prosthesis – External No benefit. Limited to R20 100 per family.


Joint replacement surgery (except for PMBs). PMBs subject to prosthesis limits:■■ Hip replacement and other major joints R21 050■■ Knee replacement R26 600■■ Minor joints R9 950

Not applicable.

Orthopaedic and medical appliances 100% Scheme tariff. Limited to R5 100 per family. 100% Scheme tariff.



Specialised diagnostic imaging 100% Scheme tariff.

Oncology PMBs at DSP State Facilities where available. Oncology programme. 100% Scheme tariff.

Peritoneal dialysis and haemodialysis PMBs only at DSPs. 100% Scheme tariff. Only at DSPs.


Refractive surgery No benefit. 100% Scheme tariff. Limited to R7 350 per eye.

In-hospital benefitsAll benefits below are subject to pre-authorisation and clinical protocols and designated hospital networks.

Pulse1 Pulse2Midwife-assisted births 100% Scheme tariff.




Co-payments Co-payment where procedure has been clinically approved: ■■ R2 950 on all laparoscopic procedures, ■■ R2 950 on prostate procedures, ■■ R2 950 on procedures for prolapse/incontinence, ■■ R2 950 on arthroscopy other than acute trauma, ■■ R2 950 on endoscopy investigations done

primarily in hospital,■■ Co-payment of up to R10 000 per event for

voluntary use of a non-DSP hospital.

Co-payment of up to R10 000 per event for voluntary use of a non-DSP hospital.


Pulse1 Pulse2Overall day-to-day limit N/A M = R11 350, M1+ = R22 550.

GP consultations

Unlimited GP visits. Subject to Bestmed Pulse1 GP networks. Out-of-network GP visits limited to R1 100

per family per year.

Unlimited GP visits at Bestmed GP Network Providers.Two out-of-network GP visits limited to

R1 200 per family.

Specialist consultations Three specialist visits limited to R1 100 per visit per family. Subject to Bestmed specialist DSP network.

Specialist consultations must be referred and approved by Network Provider limited M R2 350, M1+ R4 800.

Subject to day-to-day overall limit.

Basic and specialised dentistry Basic dentistry: Subject to Bestmed Pulse Dental Network. Specialised dentistry: No benefit.

Specialised dentistry is subject to pre-authorisation. Limited to M=R5 700, M1+ =R7 250(Subject to day to day overall limit).


No benefit. Limited to R8 100 per family. Limit on wheelchairs of R10 400 per family, per 48 months. Limit on hearing

aids of R22 450 per beneficiary per 24 months. (Subject to DSP)

Supplementary services No benefit. Limited to M = R3 350, M1+ = R6 600. (Subject to overall day-to-day limit)


No benefit. Limited to R7 750 per family.

Optometry benefit(PPN capitation provider)

Consultation R325Frame R195 AND

Single vision lenses R165 ORBifocal lenses R360 OR

Multifocal lenses R360 ORContact lenses R400

Consultation R350Frame R550 AND

Single vision lenses R165 ORBifocal lenses R360 OR

Multifocal lenses R660 ORContact lenses R1 210

Maternity benefits Subject to Provider Network. Protocols apply. 2 sonars and up to 12 antenatal consultations.


Subject to Provider Network. Protocols and tariff list apply.

Referral by NP required.

Subject to NP protocols and tariff list. (Subject to overall day-to-day limit).

Referral by NP required. Subject to pre-authorisation.

Specialised diagnostic imaging No benefit. Subject to pre-authorisation. MRI/ CT scans: A maximum of 3 scans per beneficiary.

PET scans: 1 scan per beneficiary.

Oncology PMB only. State Facilities where available. Oncology programme. 100% Scheme tariff.

Rehabilitation services after trauma No benefit.

Out-of-hospital benefitsNote: Granting of benefits under the primary care services and the Scheme benefits shall be subject to treatment protocols, preferred providers, DSPs, dental procedure codes, pathology and radiology lists of codes and medicine formularies as accepted by the Scheme.

Pul

se


Pulse

Prescribed Minimum Benefits (PMBs) are benefits that you as a member are entitled to regardless of the medical scheme option you have selected. PMBs, where indicated, include medicine.

A network only option range means that on this benefit option, you have a list of designated services providers (DSPs) that are allocated for your needs. If you use a provider that is not a DSP, you could incur additional costs.

Pulse1 Pulse2Preventative care


■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations ■■ DBC programme■■ Biometric screenings (Health Check)■■ Female contraceptives R1 800 per family per annum

■■ Flu vaccines ■■ Pneumonia vaccines■■ Paediatric immunisations■■ DBC programme■■ Biometric screenings (Health Check)■■ Female contraceptives R1 800 per family per annum

Disclaimer on exclusions: General and option specific exclusions apply. Please refer to www.bestmed.co.za for more details.

Preventative care benefitsNote: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and Mediscor Reference Price (MRP). DSPs may apply.

Pulse1 Pulse2CDL & PMB chronic medicine 100% Scheme tariff. 40% co-payment on non-formulary

medicine. 100% Scheme tariff.

25% co-payment on non-formulary medicine.

Non-CDL chronic medicine No benefit. 16 conditions. 85% Scheme tariff if prescribed by a NP. Limited to M = R5 450, M1+ = R10 800.



No benefit. Limited to R122 000 per beneficiary.

Acute medicine Subject to Provider Network Formulary. 100% Scheme tariff.

Subject to Provider Network Formulary. Limited to M = R3 600, M1+ = R7 200. 100% Scheme

tariff. (Subject to overall day-to-day limit)

Over-the-counter (OTC) medicine Limited to R300 per family.Subject to provider network formulary.

Limited to R525 per family.Subject to provider network formulary.

MedicineNote: Benefits mentioned below may be subject to pre-authorisation, formularies, funding guidelines and Mediscor Reference Price (MRP). DSPs may apply. Approved CDL, PBM and non-CDL chronic medicine costs will pay from the non-CDL chronic medicine limit first. Once the limit is depleted, CDL and PMB chronic medicine will continue to pay unlimited from Scheme risk. Note: Refer to the Chronic Conditions List at the back of the Comparative Guide.

With us you get the best when it comes to accessing quality healthcare.

AbbreviationsDBC = Documentation Based Care (Back Rehabilitation Programme); DSP = Designated Service Provider; GP = General Practitioner or Doctor; Health Check = Biometric Screenings; M = Member; M1+ = Member and family; MRI/CT scans = Magnetic Resonance Imaging/Computed Tomography scans; MRP = Mediscor Reference Price; NP = Network Provider; PET scan = Positron Emission Tomography scan; PMB = Prescribed Minimum Benefits; PSA = Prostate Specific Antigen.

Contributions

*You only pay for a maximum of four children. All other children join as beneficiaries on the Scheme free of charge. This is not applicable to Pulse1.

Pulse1 Pulse2Income level R0 – R5 500 p.m. R5 501 – R8 500 p.m. > R8 501 p.m. N/A

PRINCIPAL MEMBER

Risk R1 265 R1 518 R1 823 R4 365

Savings R0 R0 R0 R0

Total R1 265 R1 518 R1 823 R4 365

ADULT DEPENDANT

Risk R1 202 R1 443 R1 640 R4 365

Savings R0 R0 R0 R0

Total R1 202 R1 443 R1 640 R4 365

CHILD DEPENDANT

Risk R760 R911 R911 R1 037

Savings R0 R0 R0 R0

Total R760 R911 R911 R1 037

Maximum contribution child dependant*

Not applicable. 4


Not applicable. Under 21, unless a registered student.


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4Ec

zem

a√

√√

√√

√√

non-

CDL

5M

igra

ine

prop

hyla

xis

√√

√√

√√

√

non-

CDL

6G

out

prop

hyla

xis

√√

√√

√√

non-

CDL

7M

ajor

dep

ress

ion

√√

√√

√√

non-

CDL

8O

bses

sive

com

puls

ive

diso

rder

√√

√√

√

non-

CDL

9O

steo

poro

sis

√√

√√

non-

CDL

10

Psor

iasi

s√

√√

√

non-

CDL

11

Urin

ary

inco

ntin

ence

√√

√√

non-

CDL

12

Page

t’s d

isea

se√

√√

√

non-

CDL

13

Gas

tro

oeso

phag

eal r

eflux

dis

ease

(GO

RD

)√

√√

√

non-

CDL

14

Ank

ylos

ing

spon

dylit

is√

√√

non-

CDL

15

Hyp

opit

uita

rism

√

non-

CDL

16

Ost

eoar

thrit

is√

√√

√

non-

CDL

17

Alz

heim

er's

dis

ease

√√

√√

non-

CDL

18

Colla

gen

dise

ases

√√

√

non-

CDL

19

Der

mat

omyo

siti

s√

√√

non-

CDL

20

Mot

or n

euro

n di

seas

e√

non-

CDL

21

Neu

ropa

thy

√√

non-

CDL

22

Poly

arte

ritis

nod

osa

√

non-

CDL

23

Scle

rode

rma

√

non-

CDL

24

Sjog

ren'

s di

seas

e√

non-

CDL

25

Trig

emin

al n

eura

lgia

√

non-

CDL

26

Psor

iati

c ar

thrit

is√

PM

B

PMB

1A

plas

tic

anae

mia

√√

√√

√√

√√

√√

PMB

2Ch

roni

c an

aem

ia√

√√

√√

√√

√√

√

PMB

3B

enig

n pr

osta

tic

hype

rtro

phy

√√

√√

√√

√√

√√

PMB

4Cu

shin

g’s

dise

ase

√√

√√

√√

√√

√√

PMB

5Cy

stic

fibr

osis

√√

√√

√√

√√

√√

PMB

6En

dom

etrio

sis

√√

√√

√√

√√

√√

PMB

7Fe

mal

e m

enop

ause

√√

√√

√√

√√

√√

PMB

8Fi

bros

ing

alve

olit

is√

√√

√√

√√

√√

√

PMB

9G

rave

’s d

isea

se√

√√

√√

√√

√√

√

PMB

10

Hyp

erth

yroi

dism

√√

√√

√√

√√

√√

PMB

11

Hyp

ophy

seal

ade

nom

a√

√√

√√

√√

√√

√

PMB

12

Idio

path

ic t

hrom

bocy

tope

nic

purp

ura

√√

√√

√√

√√

√√

PMB

13

Para

pleg

ia /

Qua

drip

legi

a√

√√

√√

√√

√√

√

PMB

14

Poly

cyst

ic o

varia

n sy

ndro

me

√√

√√

√√

√√

√√

PMB

15

Pulm

onar

y em

bolis

m√

√√

√√

√√

√√

√

PMB

16

Stro

ke√

√√

√√

√√

√√

√

Chro

nic

Cond

itio

ns L

ist

The

Chro

nic

Dis

ease

Lis

t (C

DL)

pro

vide

s co

ver f

or t

he 2

7 li

sted

chr

onic

con

diti

ons

for w

hich

med

ical

sch

emes

mus

t co

ver t

he d

iagn

osis

, med

ical

man

agem

ent

and

med

icin

es a

s pu

blis

hed

by t

he C

ounc

il fo

r Med

ical

Sch

emes

. An

addi

tion

al 1

6 c

ondi

tion

s ar

e co

vere

d as

Pre

scrib

ed M

inim

um B

enefi

ts (P

MB

), w

here

the

med

ical

man

agem

ent

and

med

icin

es is

als

o co

vere

d fr

om S

chem

e be

nefi

ts. N

on-C

DL

chro

nic

cond

itio

ns a

re t

hose

add

itio

nal c

ondi

tion

s th

at B

estm

ed p

rovi

des

chro

nic

med

icin

e co

ver f

or.

Aut

horis

atio

n fo

r CD

L, P

MB

and

non

-CD

L ch

roni

c m

edic

ines

is s

ubje

ct t

o cl

inic

al f

undi

ng g

uide

lines

and

pro

toco

ls, f

orm

ular

ies

and

Des

igna

ted

Serv

ice

Prov

ider

s (D

SPs)

whe

re a

pplic

able

. App

rove

d CD

L an

d PM

B c

hron

ic m

edic

ines

are

cov

ered

wit

hout

an

annu

al fi

nanc

ial l

imit

whi

le n

on-C

DL

chro

nic

med

icin

es a

re s

ubje

ct t

o an

ann

ual fi

nanc

ial l

imit

. Bel

ow is

the

list

of

CDL,

PM

B a

nd n

on-C

DL

cond

itio

ns t

hat

Bes

tmed

cov

ers

on t

he v

ario

us b

enefi

t op

tion

s.

086 000 2378

[email protected]

012 472 6500

www.bestmed.co.za

@BestmedSocial

www.facebook.com/ BestmedMedicalScheme

General contact details

WALK-IN FACILITYBlock A, Glenfield Office Park361 Oberon AvenueFaerie Glen, Pretoria, 0081, South Africa

POSTAL ADDRESSP. O. Box 2297, Arcadia, Pretoria, 0001, South Africa

ER24 AND INTERNATIONAL TRAVEL COVERTel: 084 124

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CLAIMSTel: 086 000 2378 E-mail: [email protected] (queries) [email protected] (claim submissions)

BESTMED HOTLINE, OPERATED BY KPMGShould you be aware of any fraudulent, corrupt or unethical practices involving Bestmed, members, service providers or employees, please report this anonymously to KPMG.

Hotline: 080 111 0210 toll-free from any Telkom line Hotfax: 080 020 0796 Hotmail: [email protected]: KPMG Hotpost at BNT 371 P. O. Box 14671, Sinoville, 0129, South Africa

MATERNITY CARETel: 086 111 1936E-mail: [email protected]

INFANT CARETel: 086 111 1936E-mail: [email protected]

707259 Bestmed Comparative Guide. This brochure was printed in October 2016. For the most recent version of this guide, please visit our website at www.bestmed.co.za © Bestmed Medical Scheme 2016 Bestmed Medical Scheme is a registered medical scheme (reg. no. 1252) and an Authorised Financial Services Provider (FSP no. 44058).

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