Comparative guide 2018 - personally yours
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Comparative
guide
2018
personally yours
Personally
Yours
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 around 95 000 principal members and provides
healthcare benefits to 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 benefit options 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 BetterMe. 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.
2 Bestmed Comparative Guide 2018
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.
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 160 employer
organisations, including large corporate businesses, some of South Africa’s biggest universities and a variety of
parastatals.
Bestmed Provider Network
Bestmed has over the past six 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 (PMBs).
The Specialist Network, which includes all the major specialist disciplines is a Designated Service Provider network.
Currently there are around 1 700 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.
Since 1 May 2016 members have been 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.
Bestmed Comparative Guide 2018 3
Don’t worry, be Appy!
The Bestmed App has now been completely updated, with a fresh new look and better features to save
you time and money.
It’s more user-friendly, and has been designed to put all your essential medical information at your
fingertips.
The new Bestmed App is just one more way that Bestmed is Personally Yours.
To make the most of the new features, remove the old App from your phone and download the new version
from the App Store or Google Play.
You’ll notice that the updated App has a new icon, and an easy-to-use slide-out menu that lets you:
• Download your tax certificate.
• Get automatic updates on Scheme communications.
• Find information on all benefits.
• Update your personal details.
• Submit your chronic medication claims.
• Search for a specialist in your area.
Remember to remove the old version of the Bestmed App from your smartphone before downloading the
new version and stay Appy with Dr Bestie.
Want all your
medical
information at
your fingertips?
Don’t worry, be Appy!
4 Bestmed Comparative Guide 2018
Below is a summary of the current Bestmed Provider networks:
Family practitioners
Family practitioner Pulse1 network
Specialists
Pulse specilaist DSP network
Pathology
Oncology
Healthcare Provider Networks
Pharmacies
Dentists
Dental network Pulse1 and Pulse2
Dental therapists
Dental technicians
Orthodontists
Audiologists and speech therapists
Physiotherapists
Occupational therapists
Hearing aid acousticians
Ancillary Networks Counsellors
Midwives and nursing
Psychologists
Biokineticists
Dieticians
Stents and pacemakers
Orthopaedic prosthesis
Oxygen supply
Product Supply Networks
Sleep apnoea devices
Stoma Care
Hearing aid devices
Drug and alcohol rehabilitation
Emergency services
Optometry services
Service Networks Renal dialysis
Wound therapy
DBC programme
HIV/AIDS Care
The Bestmed Networks apply to all options.
Bestmed has the
widest hospital
network range in
South Africa.
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.
Bestmed Comparative Guide 2018 5
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 and Maternity Care.
Oncology Care
Bestmed’s various Scheme options have specified benefits that define the cover for cancer. 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 ICON protocols where it is clinically appropriate whilst the other options only have access to the
standard ICON protocols.
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 (LifeSense) 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.
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.
Details can be obtained by contacting LifeSense Managed Care, using the contact details provided on the
back of this guide. The Clicks and Dis-Chem courier service or retail outlets as well as Medipost courier
service are the designated service providers for dispensing of HIV medicine.
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. 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.
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.
6 Bestmed Comparative Guide 2018
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:
• Members are assisted to obtain the relevant Scheme authorisation for their stoma products.
• Members are provided with direct contact details for the supplier’s business unit to address
all their product-related enquiries.
• Members 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 Scheme.
• Direct submission of claims to Bestmed to ensures that members 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
optionspecific 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 vaccinations, members will have minimum or no co-payments.
Pneumonia vaccines: Bestmed identifies high-risk members, who receive a letter to advise
them that they are eligible for a pneumonia vaccination.
Paediatric immunisations: Bestmed reimburses vaccines for children as listed on the
Department of Health vaccine schedule on all Bestmed options, except for Beat1.
Back and neck preventative treatment: Documentation Based Care (DBC) and workability are
providers for Bestmed’s back and neck treatment programme.
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 treatment.
The 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 or Workability clinic and have an assessment done by the clinic who will
then motivate if the member qualifies for this programme. The member can thereafter send the
application to Bestmed for authorisation.
Bestmed Comparative Guide 2018 7
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
26 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 950 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 as
well as 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 as well
as 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.
BetterMe programme (available from 2018)
Until now the only preventive benefits we have provided in the options with regard to lifestyle
management programmes, were the inclusion of the health risk assessments for adult beneficiaries.
We have now decided to include more assessments in the programme that will be of benefit to all
beneficiaries.
These additional assessments are aimed at identifying the risk areas of the total family and no longer
only the adult beneficiaries. By including these, parents will be able to take note of their children’s
health risks and make the necessary steps and changes in assisting them to address these risk areas.
Health risk assessments (biometric screening and lifestyle questionnaire): These assessments
will be done by either the network pharmacies or onsite at your employer organisation during their
wellness days or similar events. All beneficiaries older than 21 will have access to this assessment.
Having this assessment done – will unlock the following further assessments that are all part of the
BetterMe preventive benefit package. All assessments should be done at contracted providers.
Fitness assessment: All beneficiaries 13 years and older will be able to undergo a detailed fitness
assessment once a year at a registered BASA accredited biokineticist.
Nutritional assessment: Families will have access to one nutritional assessment at a contracted
dietician to assess their current status of their diet.
Occupational therapist assessment: Each beneficiary ages 3 to 12 years will qualify for one
complete assessment.
Baby growth assessments: Each beneficiary ages 0 months to 35 months will qualify for three
consultations at a Bestmed contracted pharmacy clinic per year. During these consultations the
baby’s height and weight will be measured and captured in order to monitor the child’s health and
development. This new offering will replace the Infant Care programme.
Based on the results received from all the contracted providers doing the assessments, families will be
able to receive a detailed report indicating what their health status or health risks are and how they
should go about in addressing these, should it be required.
For more information regarding the BetterMe programme, please send an email to
betterme@bestmed.co.za or fax to 012 472 6787.
8 Bestmed Comparative Guide 2018
Maternity Care
Our Maternity Care programme is designed to give you information and support during your
pregnancy.
Registering on this programme will give you the following support and benefits:
• A 24-hour help line.
• Weekly e-mails with helpful tips about your pregnancy, your baby’s development and how
to deal with unpleasant pregnancy symptoms.
• During your pregnancy you will receive a welcome pack and other small surprises:
• Baby bag.
• Pregnancy guide.
• Discount vouchers.
• Various baby items.
• Register on the Maternity Care programme simply by sending an e-mail to
info@babyhealth.co.za 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.
Bestmed is the
only Scheme that
covers midwife-
assisted births
at 100% of
Scheme tariff, on
all options.
Bestmed Comparative Guide 2018 9
Beat
The Beat 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.Method of Scheme benefit payment
Beat1 Beat2 Beat3 Beat4
• In-hospital services are paid • In-hospital services are paid from • In-hospital services are paid from • In-hospital services are paid from
from Scheme risk. Scheme risk. Scheme risk. Scheme risk.
• Some preventative care • Some preventative care services • Some day-to-day services are paid • Some out-of-hospital services are
services are available from are available from Scheme risk. from Scheme risk and some from paid from your medical savings
Beat
Scheme risk. your medical savings account. account first, once depleted, from
Beat
• Out-of-hospital services are paid
• Out-of-hospital services are from your medical savings account. • Some preventative care services your day-to-day benefit.
paid from your own pocket. are available from Scheme risk. • Some preventative care services
are available from Scheme risk.
Beat Network plan option
• Bestmed offers members a choice of network hospitals for in-hospital benefits.
• If a member voluntarily chooses not to make use of a hospital within the Beat network, a maximum co-payment of R10 000 will apply for the use of a non-
designated service provider.
• The Family Practitioner (FP) consultation benefit is limited to Bestmed network providers.
• Specialist consultations are limited to Bestmed designated service providers.
In-hospital benefits
Note: Benefits mentioned below are subject to pre-authorisation and clinical protocols.
Beat1 Beat2 Beat3 Beat4
Accommodation (hospital stay) 100% Scheme tariff. 100% Scheme tariff.
and theatre fees DSP specialist network applicable if the discounted Network option is chosen.
Take-home medicine 100% Scheme tariff. Medicine limited to 7 days.
Treatment in mental health clinics 100% Scheme tariff. Limited to 21 days per beneficiary.
Treatment of chemical and 100% Scheme tariff.
substance abuse Limited to 21 days or R27 200 per beneficiary. Subject to network facilities.
Consultations and procedures 100% Scheme tariff. 100% Scheme tariff.
DSP specialist network applicable if the discounted Network option is chosen.
Surgical procedures and anaesthetics 100% Scheme tariff. Day clinics. 100% Scheme tariff.
Organ transplants 100% Scheme tariff (only PMBs).
Major medical maxillofacial surgery No benefit. (PMBs only at DSP day hospitals). 100% Scheme tariff. 100% Scheme tariff.
strictly related to certain conditions Limited to R10 900 per Limited to R11 100
family. per family.
Dental and oral surgery No benefit. (PMBs only at DSP day hospitals). Limited to R6 800 Limited to R8 500
per family. per family.
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.
Are you scheduled
for a medical
procedure in the
near future? Be
sure to obtain pre-
authorisation before
you go.
Bestmed Comparative Guide 2018 11In-hospital benefits (continued)
Beat1 Beat2 Beat3 Beat4
Prosthesis (Subject to preferred 100% Scheme tariff. Limited to R66 400 100% Scheme tariff. 100% Scheme tariff.
provider, otherwise limits and co- per family. Limited to R67 100 per Limited to R81 900
payments apply) family. per family.
Beat
Prosthesis – Internal Sub-limits per beneficiary: Sub-limits per beneficiary: Sub-limits per beneficiary:
• *Functional limited to R11 880. • *Functional limited to • *Functional limited to
Note: Sub-limit subject to R11 880. R14 300.
• Vascular R26 500.
the above prosthesis limit.
• Pacemaker (dual chamber) R36 200. • Vascular R26 600. • Vascular R28 300.
*Functional: Items utilised • Endovascular and catheter-based procedures - no • Pacemaker (dual • Pacemaker (dual
towards treating or supporting benefit. chamber) R36 200. chamber) R47 400.
a bodily function • Spinal R26 500. • Endovascular and • Endovascular and
catheter-based catheter-based
• Artificial disk - no benefit. procedures - no benefit. procedures - no benefit.
• Drug-eluting stents - no benefit. • Spinal R26 600. • Spinal R28 300.
• Mesh R9 300. • Artificial disk - no • Artificial disk -
• Gynaecology/Urology R7 600. benefit. no benefit.
• Lens implants R5 800 per lens. • Drug-eluting stents - no • Drug-eluting stents
benefit. R15 900.
• Mesh R9 350. • Mesh R10 500.
• Gynaecology/Urology • Gynaecology/Urology
R7 720. R7 700.
• Lens implants R5 800 • Lens implants R6 000
per lens. per lens.
Prosthesis – External No benefit Limited to R19 700
per family.
Exclusions (Prosthesis Joint replacement surgery (except for PMBs). Joint replacement surgery Joint replacement surgery
sub-limit subject to preferred PMBs subject to prosthesis limits: (except for PMBs). (except for PMBs).
provider, otherwise limits and PMBs subject to prosthesis PMBs subject to prosthesis
• Hip replacement and other major joints R27 900.
co-payments apply) limits: limits:
• Knee replacement R34 400. • Hip replacement and • Hip replacement and
• Minor joints R10 700. other major joints other major joints
R28 100. R29 100.
• Knee replacement • Knee replacement
R34 770. R38 660.
• Other minor joints • Other minor joints
R10 700. R11 880.
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 No benefit. PMBs only at DSPs. 100% Scheme tariff.
haemodialysis Subject to pre-
authorisation
Confinements 100% Scheme tariff.
Refractive surgery No benefit. 100% Scheme tariff. 100% Scheme tariff.
Subject to pre- Subject to pre-authorisation
authorisation and protocols. and protocols. Limited to
Limited to R7 000 per eye. R7 900 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 200 on all endoscopic investigations Co-payment of Not applicable.
and specialised diagnostic imaging if done in a private R3 200 on all endoscopic
hospital. Any other facility, no co-payment. investigations if done in a
private hospital. Any other
facility, no co-payment.
12 Bestmed Comparative Guide 2018Out-of-hospital benefits
Note: Benefits mentioned below are subject to Scheme tariff, and may also be subject to pre-authorisation and clinical protocols.
Beat1 Beat2 Beat3 Beat4
Overall day-to-day limit Not applicable. M = R10 800, M1+ = R21 600.
Beat
Family Practitioner (FP) and No benefit. Savings first. FP and specialist consultations only at Savings first.
specialist consultations Bestmed DSPs at network tariffs. Limited to M = R2 750,
M1+ = R4 900. (Subject to overall
day-to-day limit)
Basic and specialised dentistry No benefit. Basic: Preventative benefit or savings account. Savings first.
Specialised: Savings account. Limited to M = R4 650,
Orthodontic: Subject to pre-authorisation. M1+ = R9 340. (Subject to overall
day-to-day limit). Orthodontics
are subject to pre-authorisation.
Medical aids, apparatus and No benefit. Savings account. Savings first. 100% Scheme
appliances including wheelchairs tariff. Limited to R9 700 per
and hearing aids family. (Subject to overall
day-to-day limit)
Supplementary services No benefit. Savings account. Savings first.
Limited to M = R4 200,
M1+ = R8 530. (Subject to overall
day-to-day limit)
Wound care benefit (incl. 100% Scheme tariff. Savings first. 100% Scheme
dressings, negative pressure Limited to R 2 970 per family. tariff. Limited to R4 200 per
wound therapy treatment and family. (Subject to overall
related nursing services - out-of- day-to-day limit)
hospital)
Optometry benefit No benefit. Savings account. Consultation R365.
(PPN capitation provider) Frame R550 AND
Single-vision lenses R175 OR
Bifocal lenses R380 OR
Multifocal lenses R695.
Contact lenses R1 420
Diagnostic imaging No benefit. Savings account. Savings first.
and pathology Limited to M = R2 750,
M1+ = R5 600. (Subject to overall
day-to-day limit)
Specialised diagnostic imaging 100% Scheme tariff. 100% Scheme tariff. 100% Scheme tariff.
Limited to R4 500 per family. Limited to R9 450 per Limited to R14 300 per family.
family.
Oncology PMB only Oncology programme.
100% Scheme tariff.
Maternity benefits No benefit. Savings account. 100% Scheme tariff.
2 sonars and up to 12 antenatal consultations.
Rehabilitation services No benefit. Savings account. Vested savings.
after trauma
Bestmed Comparative Guide 2018 13Medicine
Note: 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 be paid from the non-CDL chronic medicine limit first. Once the limit is depleted, CDL and PMB
chronic medicine will be unlimited from Scheme risk.
Note: Refer to the Chronic Conditions List at the back of the Comparative Guide.
Beat1 Beat2 Beat3 Beat4
Beat
CDL & 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. 9 conditions.
75% Scheme tariff. Limited to 85% Scheme tariff. Limited to
M = R2 900, M1+ = R5 900. M = R6 370, M1+ = R12 740.
Co-payment of 40% for Co-payment of 30% for
non-formulary medicine. non-formulary medicine.
Biologicals and other No benefit.
high-cost medicine
Acute medicine No benefit. Savings account. Savings first. Limited to
M = R2 430, M1+ = R4 910.
(Subject to overall
day-to-day limit)
Over-the-counter (OTC) medicine No benefit. Savings account. *Member choice: 1. R550 OTC
See benefit option rules limit OR 2. Access to full PMSA
for OTC purchases (after R550
limit) = self-payment gap
accumulation.
*The default OTC choice is 1. R550 OTC limit. Members wishing to choose the other option are welcome to contact Bestmed.
Preventative care benefits
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP).
Beat1 Beat2 Beat3 Beat4
Preventative care • Flu vaccines. • Flu vaccines. • Flu vaccines. • Flu vaccines.
benefits • Pneumonia vaccines. • Pneumonia vaccines. • Pneumonia vaccines. • Pneumonia vaccines.
• Female contraceptives - • Paediatric immunisations. • Paediatric immunisations. • Paediatric immunisations.
Note: Refer to Scheme R1 950 per family per year. • Female contraceptives - • Female contraceptives - • Female contraceptives -
rules for funding
• DBC programme. R 1 950 per family per R1 950 per family per year. R1 950 per family per year.
criteria applicable to
• Pap smear – ages 18 and year. • DBC programme. • DBC programme.
each preventative
above, every 24 months. • DBC programme. • Preventative dentistry. • Preventative dentistry.
care benefit.
• Preventative dentistry. (incl. gloves and sterile (incl. gloves and sterile
(incl. gloves and sterile equipment) equipment).
equipment) • Pap smear – ages 18 and • Haemophilus influenzae
• Pap smear – ages 18 and above, every 24 months. Type B vaccine. (HIB).
above, every 24 months. • Mammogram.
• HPV vaccinations.
• PSA Screening - ages
50 years and above, every
24 months.
• Pap smear – ages 18 and
above, every 24 months
BetterMe wellness • Health risk assessment (biometric screening) at contracted pharmacy or on-site at employer.
benefits • Fitness assessment at a contracted BASA biokineticist - 1 per beneficiary per year (ages older than 13 years).
• Nutritional assessment - 1 per family per year.
Note: Biometric
screening activates • Occupational therapy assessment - 1 per beneficiary per year (ages 3-12 years).
the other assessment • Baby growth assessment at a contracted pharmacy clinic - 3 per beneficiary per year (ages 0-35 months).
benefits.
Disclaimer on exclusions: General and option-specific exclusions apply. Please refer to www.bestmed.co.za for more details.
14 Bestmed Comparative Guide 2018Contributions
Beat1 Beat2 Beat3 Beat4
Non-Network (NN)/
NN N NN N NN N NN
Network (N)
Risk R1 363 R1 226 R1 398 R1 259 R2 123 R1 909 R3 334
Beat
PRINCIPAL MEMBER Savings R0 R0 R287 R258 R435 R392 R588
Total R1 363 R1 226 R1 685 R1 517 R2 558 R2 301 R3 922
Risk R1 058 R953 R1 087 R978 R1 508 R1 358 R2 753
ADULT DEPENDANT Savings R0 R0 R223 R200 R309 R278 R486
Total R1 058 R953 R1 310 R1 178 R1 817 R1 636 R3 239
Risk R573 R516 R589 R530 R819 R738 R824
CHILD DEPENDANT Savings R0 R0 R121 R109 R168 R151 R146
Total R573 R516 R710 R639 R987 R889 R970
Maximum contribution 4
child dependants*
Recognition of a child Under 21, unless a registered student.
dependant
* You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.
Abbreviations
CDL = Chronic Disease List; DBC = Documentation Based Care (back rehabilitation programme); DSP = Designated Service Provider;
FP = Family Practitioner or Doctor; BetterMe = 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 Benefit;
PMSA = Personal Medical Savings Account; PPN = Preferred Provider Negotiator; PSA = Prostate Specific Antigen.
For a more detailed overview of your benefit option and to receive a membership guide please contact service@bestmed.co.za
Disclaimer: All the 2018 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 2018 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.
Bestmed Comparative Guide 2018 15Pace
The Pace range offers
more comprehensive in-
hospital and out-of-hospital
benefits. 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.Method of Scheme benefit payment
Pace1 Pace2 Pace3 Pace4
• In-hospital services are paid from Scheme risk benefit. Some out-of-hospital services are paid from • In-hospital services, out-of-hospital services and
the annual savings first and once depleted will be paid from the day-to-day benefit. preventative care services are paid from Scheme
• Once the day-to-day benefit is depleted, services can be paid from the available vested savings. risk benefit.
Some preventative care services are available from Scheme risk benefit. • Once out-of-hospital risk benefits are depleted,
further claims will be paid from savings.
In-hospital benefits
Note: All benefits mentioned below are subject to pre-authorisation and clinical protocols.
Pace1 Pace2 Pace3 Pace4
Accommodation (hospital stay) and
100% Scheme tariff.
theatre fees
Take-home medicine 100% Scheme tariff. Medicine limited to 7 days.
Treatment in mental health
100% Scheme tariff. Limited to 21 days per beneficiary.
clinics
Treatment of chemical and 100% Scheme tariff.
substance abuse Limited to 21 days or R27 200 per beneficiary. Subject to network facilities.
Consultations and procedures 100% Scheme tariff.
Surgical procedures and
100% Scheme tariff.
anaesthetics
Organ transplants 100% Scheme tariff. 100% Scheme tariff.
(Only PMBs)
Major medical maxillofacial 100% Scheme tariff. 100% Scheme tariff.
surgery strictly related to certain Limited to R11 000
conditions per family.
Pace
Dental and oral surgery Limited to R6 800 Limited to R11 300 Limited to R14 200 Limited to R17 000
per family. per family. per family. per family.
Prosthesis (Subject to preferred 100% Scheme tariff. 100% Scheme tariff. 100% Scheme tariff. 100% Scheme tariff.
provider, otherwise limits and Limited to R76 000 Limited to R97 600 Limited to R98 100 Limited to R113 200
co-payments apply) per family. per family. per family. per family.
Prosthesis – Internal Sub-limits per beneficiary: Sub-limits per beneficiary: Sub-limits per beneficiary: Sub-limits per beneficiary:
• *Functional limited to • *Functional limited to • *Functional limited to • *Functional limited to
Note: Sub-limit subject to R13 650. R14 850. R16 000. R16 600.
the above prosthesis limit. • Vascular R27 700. • Vascular R36 600. • Vascular R36 700. • Vascular R42 000.
• Pacemaker (dual • Pacemaker (dual • Pacemaker (dual • Pacemaker (dual
*Functional: Items utilised
chamber) R47 300. chamber) R52 750. chamber) R52 750. chamber) R52 750.
towards treating or supporting
a bodily function • Endovascular and • Spinal R36 600. • Spinal R36 700. • Spinal R42 000.
catheter-based • Artificial disk R16 000. • Artificial disk • Artificial disk R18 850.
procedures - no benefit. R16 000.
• Drug-eluting stents • Drug-eluting stents
• Spinal R27 700. R16 000. • Drug-eluting stents R18 850.
• Artificial disk - no benefit. • Mesh R16 000. R16 000. • Mesh R16 600.
• Drug-eluting stents - • Gynaecology/Urology • Mesh R16 000. • Gynaecology/Urology
no benefit. R11 950. • Gynaecology/Urology R13 700.
• Mesh R10 400. • Lens implants R10 260 R12 000. • Lens implants R15 170
• Gynaecology/Urology per lens. • Lens implants per lens.
R7 500. • Joint replacements: R10 260 per lens. • Joint replacements:
• Lens implants R5 700 1. Hip replacement and • Joint replacements: 1. Hip replacement and
per lens. other major joints 1. Hip replacement other major joints
R43 950. and other major R50 650.
2. Knee replacement joints R44 000 2. Knee replacement
R51 000. 2. Knee replacement R58 650.
3. Minor joints R18 950. R51 250. 3. Minor joints R18 850.
3. Minor joints
R18 950.
Bestmed Comparative Guide 2018 17Generic medicines
are always available
at a lower cost than
the original brand and
are just as effective.
Bestmed recommends
using these generic
alternatives to avoid
incurring additional
costs.
Did you know
that Bestmed’s
Pace option range
does not have
co-payment or
automatic self-
payment gaps?
In-hospital benefits (continued)
Pace
Pace1 Pace2 Pace3 Pace4
Prosthesis – External Limited to R19 300 Limited to R23 000 Limited to R23 100 Limited to R26 100
per family. per family. per family. per family.
Exclusions (Prosthesis Joint replacement surgery Not applicable.
sub-limit subject to preferred (except for PMBs). PMBs
provider, otherwise limits and subject to prosthesis limits:
co-payments apply) • Hip replacement and
other major joints
R28 200.
• Knee replacement
R37 500.
• Minor joints R11 650.
Orthopaedic and medical 100% Scheme tariff.
appliances
Pathology 100% Scheme tariff.
Diagnostic imaging 100% Scheme tariff.
Specialised diagnostic imaging 100% Scheme tariff.
Oncology Oncology programme. Oncology programme. 100% Scheme tariff.
PMBs only at DSPs.
Peritoneal dialysis and PMBs only at DSPs. 100% Scheme tariff.
haemodialysis
Confinements 100% Scheme tariff.
Refractive surgery 100% Scheme tariff. Limited to 100% Scheme tariff. 100% Scheme tariff. Limited to R8 500 per eye.
R7 560 per eye. Limited to R7 900
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 Not applicable.
18 Bestmed Comparative Guide 2018Out-of-hospital benefits
Note: Benefits mentioned below are subject to Scheme tariff, and may also be subject to pre-authorisation and clinical protocols.
Pace1 Pace2 Pace3 Pace4
Overall day-to-day limit M = R9 180, M = R12 960, M = R16 200, M = R30 200,
M1+ = R18 360. M1+ = R25 920. M1+ = R33 480. M1+ = R48 700.
FP and specialist Savings first. Savings first. Savings first. Limited to M = R4 750,
consultations Limited to M = R1 890, Limited to M = R3 700, 100% Scheme tariff. M1+ = R7 700. (Subject to
M1+ = R3 800. (Subject to M1+ = R7 500. (Subject to M = R3 700, M1+ = R7 500. overall day-to-day limit)
overall day-to-day limit) overall day-to-day limit) (Subject to overall day-to-
day limit)
Basic and specialised Savings first. Savings first. Savings first. Limited to M = R10 250,
dentistry Basic: Preventative benefit or Basic: Preventative benefit or Basic: Preventative benefit or M1+ = R17 300. (Subject to
savings account. savings account. savings account. overall day-to-day limit)
Limit once savings exceeded. Limit once savings exceeded. Limit once savings exceeded. Orthodontic: Subject to pre-
Specialised: Savings account Specialised: Savings account Specialised: Savings account authorisation.
then limit. then limit. then limit.
Orthodontic: Subject to Orthodontic: Subject to Orthodontic: Subject to
pre-authorisation. pre-authorisation. pre-authorisation.
Limited to M = R3 400, Limited to M = R5 700, 100% Scheme tariff. Limited
M1+ = R6 900. (Subject to M1+ = R11 400. (Subject to to M = R6 150,
overall day-to-day limit) overall day-to-day limit) M1+ = R11 450. (Subject to
overall day-to-day limit)
Medical aids, apparatus Savings first. 100% Scheme Savings first. 100% Scheme Savings first. 100% Scheme 100% Scheme tariff. Limited
and appliances tariff. Limited to R9 700 per tariff. Limited to R8 800 per tariff. Limited to R8 800 per to R8 800 per family. (Subject
including wheelchairs family. (Subject to overall day- family. (Subject to overall day- family. (Subject to overall day- to overall day-to-day limit).
and hearing aids to-day limit) to-day limit). to-day limit).
Limit on wheelchairs of Limit on wheelchairs of Limit on wheelchairs of
R11 900 per family per R11 900 per family per R11 900 per family per
48 months. 48 months. 48 months.
Limit on hearing aids of Limit on hearing aids of Limit on hearing aids of
R24 250 per beneficiary per R27 300 per beneficiary per R30 400 per beneficiary per
Pace
24 months. 24 months. 24 months.
Supplementary services Savings first. Savings first. Savings first. Limited to M = R4 750,
Limited to M = R3 700, Limited to M = R4 650, Limited to M = R2 260, M1+ = R9 350. (Subject to
M1+ = R7 700. (Subject to M1+ = R9 350. (Subject to M1+ = R4 750. (Subject to overall day-to-day limit)
overall day-to-day limit) overall day-to-day limit) overall day-to-day limit)
Wound care benefit Savings first. 100% Scheme Savings first. 100% Scheme Savings first. 100% Scheme Limited to R11 600 per
(incl. dressings, negative tariff. Limited to R3 050 per tariff. Limited to R5 800 per tariff. Limited to R9 000 per family. (Subject to overall
pressure wound therapy family. (Subject to overall family. (Subject to overall family. (Subject to overall day-to-day limit)
treatment and related day-to-day limit) day-to-day limit) day-to-day limit)
nursing services - out-of-
hospital)
Optometry benefit Consultation R365 Consultation R365 Consultation R365 Consultation R365
(PPN capitation provider) Frame R550 AND Frame R550 AND Frame R550 AND Frame R550 AND
Single vision lenses R175 OR Single vision lenses Single vision lenses Single vision lenses
Bifocal lenses R380 OR R175 OR R175 OR R175 OR
Multifocal lenses R695 Bifocal lenses R380 OR Bifocal lenses R380 OR Bifocal lenses R380 OR
Contact lenses R1 420 Multifocal lenses R695 Multifocal lenses R695 Multifocal lenses R695
Contact lenses R1 420 Contact lenses R1 420 Contact lenses R1 710
Diagnostic imaging Savings first. 100% Scheme Savings first. 100% Scheme Savings first. 100% Scheme 100% Scheme tariff. Limited
and pathology tariff. Limited to M = R2 750, tariff. Limited to M = R2 750, tariff. Limited to M = R3 000, to M = R4 750, M1+ = R9 350.
M1+ = R5 500. (Subject to M1+ = R5 500. (Subject to M1+ = R5 950. (Subject to (Subject to overall day-to-
overall day-to-day limit) overall day-to-day limit) overall day-to-day limit) day limit)
Maternity benefits 100% Scheme tariff. 2 sonars and up to 12 antenatal consultations.
Specialised diagnostic 100% Scheme tariff. MRI/CT scans: Maximum of 3 scans per beneficiary.
imaging Limited to R12 300 per family. PET scan: 1 scan per beneficiary. 100% Scheme tariff.
Rehabilitation services Vested savings. 100% Scheme tariff.
after trauma
Oncology Oncology programme. Oncology programme. 100% Scheme tariff.
(PMBs only)
Bestmed Comparative Guide 2018 19Medicine
Note: 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 be unlimited from Scheme risk.
Note: Refer to the Chronic Conditions List at the back of the Comparative Guide.
Pace1 Pace2 Pace3 Pace4
CDL & PMB chronic 100% Scheme tariff. 100% Scheme tariff. 100% Scheme tariff. 100% Scheme tariff.
medicine Co-payment of 35% for Co-payment of 30% for Co-payment of 25% for Co-payment of 20% for
non-formulary medicine. non-formulary medicine. non-formulary medicine. non-formulary medicine.
Non-CDL chronic 7 conditions. 18 conditions. 19 conditions. 26 conditions.
medicine 85% Scheme tariff. 85% Scheme tariff. 85% Scheme tariff. 85% Scheme tariff.
Limited to M = R5 600, Limited to M = R7 700, Limited to M = R12 420, Limited to M = R16 750,
M1+ = R11 200. M1+ = R15 400. M1+ = R24 840. M1+ = R33 650.
Co-payment of 35% for Co-payment of 30% for Co-payment of 25% for Co-payment of 20% for
non-formulary medicine. non-formulary medicine. non-formulary medicine. non-formulary medicine.
Biologicals and other No benefit. Limited to R140 000 Limited to R280 000 Limited to R414 400
high-cost medicine per beneficiary. per beneficiary. per beneficiary.
Acute medicine Savings first. Savings first. Savings first. Limited to M = R7 500,
Limited to M = R1 980, Limited to M = R4 100, Limited to M = R1 300, M1+ = R11 650.
M1+ = R4 100. (Subject to M1+ = R8 200. (Subject to M1+ = R3 200. (Subject to (10% co-payment) (Subject to
overall day-to-day limit). overall day-to-day limit). overall day-to-day limit). overall day-to-day limit).
Over-the-counter *Member choice: 1. R550 OTC limit OR 2. Access to full PMSA for OTC purchases (after R550 Savings account.
(OTC) medicine limit) = self-payment gap accumulation.
See benefit option rules
*The default OTC choice is 1. R550 OTC limit. Members wishing to choose the other option are welcome to contact Bestmed.
Preventative care benefits
Pace
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP).
Pace1 Pace2 Pace3 Pace4
Preventative care • Flu vaccines. • Flu vaccines. • Flu vaccines.
• Pneumonia vaccines. • Pneumonia vaccines. • Pneumonia vaccines.
Note: Refer to Scheme
• Paediatric immunisations. • Paediatric immunisations. • Paediatric immunisations.
rules for funding
• Female contraceptives – • Female contraceptives – • Female contraceptives – R1 950 per family per year.
criteria applicable to each
R1 950 per family per year. R1 950 per family per year. • DBC programme.
preventative
• DBC programme. • DBC programme. • Preventative dentistry. (incl. gloves and sterile equipment).
care benefit.
• Preventative dentistry. • Preventative dentistry. • Haemophilus influenzae Type B vaccine. (HIB).
(incl. gloves and sterile (incl. gloves and sterile
equipment). equipment). • Mammogram.
• Haemophilus influenzae • Haemophilus influenzae • PSA screening - ages 50 and above, every 24 months.
Type B vaccine. (HIB). Type B vaccine. (HIB). • HPV vaccines.
• Mammogram. • Mammogram. • Bone densitometry.
• HPV vaccines. • PSA screening – ages • Pap smear – ages 18 and above, every 24 months.
• Pap smear – age 18 and 50 and above, every 24
above, every 24 months. months.
• HPV vaccines.
• Bone densitometry.
• Pap smear – age 18 and
above, every 24 months.
BetterMe wellness • Health risk assessment (biometric screening) at contracted pharmacy or on-site at employer.
benefits • Fitness assessment at a contracted BASA biokineticist - 1 per beneficiary per year (ages older than 13 years)
• Nutritional assessment - 1 per family per year
Note: Biometric
screening activates • Occupational therapy assessment - 1 per beneficiary per year (ages 3-12 years)
the other assessment • Baby growth assessment at a contracted pharmacy clinic - 3 per beneficiary per year (ages 0-35 months)
benefits.
Disclaimer on exclusions: General and option specific exclusions apply. Please refer to www.bestmed.co.za for more details.
20 Bestmed Comparative Guide 2018Contributions
Pace1 Pace2 Pace3 Pace4
Risk R2 650 R3 976 R4 565 R6 410
PRINCIPAL MEMBER Savings R662 R701 R805 R198
Total R3 312 R4 677 R5 370 R6 608
Risk R1 860 R3 898 R3 674 R6 410
ADULT DEPENDANT Savings R465 R688 R648 R198
Total R2 325 R4 586 R4 322 R6 608
Risk R669 R876 R784 R1 502
CHILD DEPENDANT Savings R167 R155 R139 R46
Total R836 R1 031 R923 R1 548
Maximum contribution
4
child dependant*
Recognition of a child Under 21, unless a registered student.
dependant
*You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.
Abbreviations
DBC = Documentation Based Care (Back Rehabilitation Programme); DSP = Designated Service Provider; FP = Family Practitioner or
Doctor; BetterMe = 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; PMSA = Personal Medical
Savings Account; 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 service@bestmed.co.za
Disclaimer: All the 2018 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 2018 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)
Pace
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.
Chat to us directly
using our Chat
Now service on the
Bestmed website.
Medicine formulary – This is a
list of prescription medicines
(both generic and brand name)
for which the Scheme will
pay. Make sure you familiarise
yourself with this list when
doctors prescribe medicine to
you.
Bestmed Comparative Guide 2018 21Pulse
The Pulse range is ideally
suitable for you if:
• You are seeking a plan option
that is based on your income.
• You are comfortable with
making use of designated
service providers (DSPs)
within our network.
• You are looking for unlimited
comprehensive cover for
hospitalisation and the added
benefit of preventative care.Method of Scheme benefit payment
Pulse1 Pulse2
• In-hospital services are paid from Scheme risk. • In-hospital services are paid from Scheme risk.
• Some preventative care services are available from Scheme risk. • Some day-to-day services and preventative care services are available
• Some out-of-hospital services are paid from Scheme risk. from Scheme risk.
• Only Pulse specialist DSP network. • Some out-of-hospital services are paid from Scheme risk.
• Only Pulse specialist DSP network.
In-hospital benefits
All benefits below are subject to pre-authorisations and clinical protocols and designated hospital networks.
Pulse1 Pulse2
Accommodation (hospital stay) and theatre fees 100% Scheme tariff at a Netcare DSP hospital.
Take-home medicine 100% Scheme tariff. Medicine limited to 3 days. 100% Scheme tariff. Medicine limited to 7 days.
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). 100% Scheme tariff.
Limited to 21 days per beneficiary. Limited to 21 days or R27 200 per beneficiary.
Subject to network facilities. Subject to network facilities.
Consultations and procedures 100% Scheme tariff.
Surgical procedures and anaesthetics 100% Scheme tariff. 100% Scheme tariff.
Excluded from benefits: functional nasal surgery,
surgery for medical conditions e.g. Epilepsy,
Parkinson’s disease and procedures where
stimulators are used.
Organ transplants 100% Scheme tariff (only PMBs).
Major medical maxillo-facial surgery strictly No benefit. 100% Scheme tariff.
related to certain conditions
Dental and oral surgery No benefit. 100% Scheme tariff.
Prosthesis (Subject to preferred provider, 100% Scheme tariff. 100% Scheme tariff.
otherwise limits and co-payments apply) Limited to R44 700 per family. Limited to R89 500 per family.
Prosthesis – Internal Sub-limits per beneficiary: Sub-limits per beneficiary:
• *Functional R9 500. • *Functional R14 850.
Note: Sub-limit subject to the • Vascular R22 150. • Vascular R34 600.
above prosthesis limit • Pacemaker (dual chamber) R36 200. • Pacemaker (dual chamber) R46 900.
• Endovascular and catheter-based procedures - • Spinal R34 600.
*Functional: Items utilised no benefit. • Artificial disk R15 200.
towards treating or supporting • Spinal R22 150. • Drug-eluting stents R15 200.
a bodily function • Artificial disk - no benefit. • Mesh R15 200.
• Drug-eluting stents - no benefit. • Gynaecology/Urology R11 300.
• Mesh R8 100. • Lens implants R9 700 per lens.
• Gynaecology/Urology R6 690. • Joint replacements:
• Lens implants R4 650 per lens. 1. Hip replacement and other major joints
R41 400.
2. Knee replacement R48 350.
3. Minor joints R18 000.
Prosthesis – External No benefit. Limited to R21 600 per family.
Exclusions (Prosthesis sub-limit subject to Joint replacement surgery (except for PMBs). Not applicable.
preferred provider, otherwise limits and PMBs subject to prosthesis limits:
co-payments apply) • Hip replacement and other major joints R22 700.
• Knee replacement R28 700.
• Minor joints R10 750.
Orthopaedic and medical appliances 100% Scheme tariff. Limited to R5 500 per family. 100% Scheme tariff.
Pathology 100% Scheme tariff.
Pulse
Diagnostic imaging 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.
Confinements 100% Scheme tariff.
Refractive surgery No benefit. 100% Scheme tariff. Limited to R7 950 per eye.
Midwife-assisted births 100% Scheme tariff.
Bestmed Comparative Guide 2018 23You can also read
