Comparative guide 2018 - personally yours - Your Health and Actuarial ...
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Comparative
guide
2018
personally yours
The Corporate Partnership Since 1 May 2016 members have been required to use a specialist
on the DSP network for services related to their PMB conditions,
Bestmed healthcare is based on sound partnerships. The way and such service will be charged and paid at the agreed DSP rate.
we engage with our corporate clients aims to establish and
maintain long-term personal relationships, built on mutual trust Should a member voluntarily choose not to use a specialist from
Personally and integrity. We further strive to provide affordable, excellent 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
Yours healthcare solutions, be accessible and provide personalised
advice to all members and be flexible so processes are easy member’s account.
to follow.
In line with this vision, Bestmed has adopted a three- Bestmed International Travel Insurance
pronged approach in order to deliver on its promise, which
includes Corporate Wellness, a Client Service Programme, Bestmed members between the ages of 3 months and 84
Our focus is to provide superior healthcare to our members through the legendary Bestmed touch. as well as Administration. Bestmed advisors are responsible years, have access to R10 million in international travel cover
for implementing these service programmes at employer through Bryte Insurance. This policy provides up to a maximum
We are, after all, a medical scheme for members, by members. Over the years Bestmed has grown of 90 (ninety) days of cover per trip, irrespective of how many
organisations. Today, Bestmed services over 160 employer
sustainably and has been able to build a reputable name in the industry. But Bestmed is still raising trips are made during the year.
organisations, including large corporate businesses, some of
the bar in the medical aid industry to the point where we have grown our membership to reach the
South Africa’s biggest universities and a variety of parastatals. How to activate your cover?
fourth overall position countrywide.
1. Please ensure that all requests for international travel cover
Bestmed belongs to its members. We deliver a service that gives personal attention to each are made at least 7 working days before the documentation
query and enquiry that a member has. Members receive personal, individual and undivided Bestmed Provider Network is required to allow for the processing of the request.
attention in all their dealings with their chosen medical scheme.
Bestmed has over the past six years, established several 2. Contact Bryte insurance on 0860 329 329 or
It is Bestmed’s every intention to ensure that every member receives the quality service that preferred and designated service provider networks with er24@brytesa.com to activate your policy.
they deserve. provider groups, an initiative designed to make sustainable,
high-quality healthcare services available to our members 3. Alternatively contact ER24 on 010 205 3100 or
As a self-administered scheme, Bestmed now has around 95 000 principal members and provides travel@er24.co.za
at affordable premiums.
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 As with any insurance product, there are terms and conditions
are, rand-for-rand, the best value compared to other large open medical schemes. applicable to the policy. Please ensure that you read the policy
Member advantages of using Bestmed document carefully to ensure you understand all the applicable
Provider Networks terms and conditions.
The right fit Making use of the Bestmed provider networks has a number Please ensure that you take note of the telephone numbers to
To address our members’ desire for choice and flexibility, Bestmed has designed advantages to both providers and members. Some of the call in the event of an emergency.
13 healthcare options which are structured differently to suit various healthcare needs. advantages include:
Exclusions to the policy:
We recognise that members’ healthcare needs will vary depending on age, marital status and • Provider fees are set and managed as agreed. • Members under 3 months or over of 84 years.
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 • Quality of healthcare services are enhanced. • Members travelling for longer than 90 days.
an option for you. • Downstream costs are better managed. • Members partaking in events that could be construed as
Our Beat, Pace and Pulse benefit options have been designed based on engagements and hazardous pursuits. Please see the policy document for which
• Providers are paid directly and on a weekly basis by
conversations with members over our many years of experience. After listening intently to their sporting events are covered.
the Scheme.
concerns, our healthcare experts have translated these insights into benefit options that are Please contact Bryte insurance on 0860 329 329 during
easy to understand and cater for all needs. • No or minimum co-payments by the members depending
business hours to enquire about any additional cover required.
on benefits available.
What to do in the event of a medical emergency:
• A longer lasting medical savings account.
Focused on wellness Please call Bryte Travel Assist on: + 1 416 642 2910 or email
• Network lists, provider names and addresses are available assistance@wtp.ca, alternatively you can call +27 10 205 3100
Your continued health and wellbeing is our primary concern. That is why we encourage all of
on the website. who will put you through to Bryte Travel Assist.
our members to live a more preventive, meaningful and productive life through our wellness
programme. We are here to assist you to become a better version of yourself through choosing a • A dedicated provider consultant service is available to Please note that all international travel claims in excess of
healthier lifestyle. the network providers. R5 000.00 must be reported to Bryte Travel Assist.
Our wellness philosophy is based on five basic wellness pillars. We encourage our members to: For all retrospective international travel claims and a claim form,
please contact Bryte Travel Claims - 0860 222 446 or
Be Active: Incorporate exercise as part of your daily routine to promote positive changes. Bestmed Designated Service Provider (DSP) travelclaims@brytesa.com
Be Safe: Make responsible lifestyle choices to prevent adverse consequences. Network for Prescribed Minimum Benefit
Be Nutri-wise: Balanced nutrition is important to maintain a healthy body and mind. (PMBs).
Be Happy: Create and maintain a balance between work, life and home. The Specialist Network, which includes all the major specialist
disciplines is a Designated Service Provider network. Currently
Be Fin-fit: Making informed financial decisions in life will ensure financial independence.
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.
2 Bestmed Comparative Guide 2018 Bestmed Comparative Guide 2018 3
Don’t worry, be Appy! Below is a summary of the current Bestmed Provider networks:
Family practitioners
The Bestmed App has now been completely updated, with a fresh new look and better features to Family practitioner Pulse1 network
save you time and money.
Specialists
It’s more user-friendly, and has been designed to put all your essential medical information at your Pulse specilaist DSP network
fingertips. Pathology
Oncology
The new Bestmed App is just one more way that Bestmed is Personally Yours. Healthcare Provider Networks
Pharmacies
To make the most of the new features, remove the old App from your phone and download the Dentists
new version from the App Store or Google Play. Dental network Pulse1 and Pulse2
Dental therapists
Dental technicians
Orthodontists
Audiologists and speech therapists
Physiotherapists
You’ll notice that the updated App has a new icon, and an easy-to-use slide-out menu that lets you:
Occupational therapists
• Download your tax certificate.
Hearing aid acousticians
• Get automatic updates on Scheme communications. Ancillary Networks Counsellors
• Find information on all benefits. Midwives and nursing
Psychologists
• Update your personal details.
Biokineticists
• Submit your chronic medication claims. Dieticians
• Search for a specialist in your area.
Stents and pacemakers
Remember to remove the old version of the Bestmed App from your smartphone before Orthopaedic prosthesis
downloading the new version and stay Appy with Dr Bestie. 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
Want all your
medical The Bestmed Networks apply to all options.
information at
your fingertips?
Don’t worry, be Appy!
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.
4 Bestmed Comparative Guide 2018 Bestmed Comparative Guide 2018 5
Alcohol and Substance Abuse Care
Bestmed Managed Care Programmes
Bestmed has contracted various designated service providers (DSPs) to provide rehabilitation for alcohol
The Managed Health Care Programmes have been developed to assist members by providing additional benefits and substance abuse. Please note that this benefit is subject to pre-authorisation and will be funded up to a
to treat the following specific disease conditions with appropriate treatment, in a cost-effective manner. These maximum limit or 21 days, or whichever is depleted first.
programmes include: Oncology Care, HIV/AIDS Care, Dialysis Care, Alcohol and Substance Abuse Care, Wound
Care, Stoma Care, Preventative Care and Maternity Care.
Wound Care
Oncology Care Specialised wound care therapy, including dressings and negative-pressure wound therapy (NPWT) treatment
Bestmed’s various healthcare options have specified benefits that define the cover for cancer. These benefits and related nursing services are included in Bestmed’s Provider Network.
are called oncology benefits.
Bestmed provides oncology benefits applying evidence-based medicine principles and considering affordability Stoma Care
across the different benefit options. We have appointed the Independent Clinical Oncology Network (ICON) for Bestmed has partnered with a supplier for the supply and distribution of stoma and incontinence care products.
all our healthcare options as the DSP. Members on Pace3 and Pace4 have access to the enhanced ICON protocols Bestmed members who are registered on Stoma Care receive the following value-added benefits:
where it is clinically appropriate whilst the other options have access to the standard ICON protocols.
• Members are assisted to obtain the relevant Scheme authorisation for their stoma products.
Members registered on the oncology programme qualify for cancer benefits. Members must forward a clinical
• Members are provided with direct contact details for the supplier’s business unit to address all their product-
summary and histology of their cancer, as set out by their treating doctor, to register on the programme. This
related enquiries.
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. • 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.
HIV/AIDS Care • Direct submission of claims to Bestmed to ensures that members do not have to pay cash up front and claim
Acquired immunodeficiency syndrome (AIDS) is a chronic, potentially life-threatening condition caused by the back from the Scheme.
human immunodeficiency virus (HIV). By damaging your immune system, this virus interferes with your body’s
ability to fight the organisms that cause disease.
Preventative Care
HIV/AIDS is a sexually transmitted infection. It can also be spread by contact with infected blood or from mother
At Bestmed we encourage our members to actively pursue a healthier and more active lifestyle to encourage
to child during pregnancy, childbirth or breastfeeding. Without medicine, it may take years before HIV weakens
better health.
your immune system to the point that you have full blown AIDS.
In line with this philosophy we have developed preventative care that entitles you, the member, to undergo a
There is currently no cure for HIV/AIDS, but there is medicine available that can dramatically slow down the
number of screenings, preventative tests and vaccines to encourage better health.
progression of the disease.
Preventative care is important in making sure you detect medical conditions early and we can ensure the best
To qualify for benefits, a member or dependant must register on the HIV/AIDS programme. A member must
care for you in this regard. Bestmed offers preventative care that covers a number of benefits from the Scheme’s
forward a clinical summary that has been obtained from the treating doctor to the DSP (LifeSense) as appointed
risk benefit, and not your savings. General and option specific exclusions may apply to the various options.
by the Scheme. This summary must contain the relevant history, clinical findings, results of the HIV/AIDS
Please refer to www.bestmed.co.za for more details.
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 Flu vaccines: All members are eligible and annually receive a letter to remind them of this preventative care
full blood count, liver function tests and specimens sent for microscopy. benefit when flu vaccines become available. By making use of preferred provider pharmacies for flu vaccinations,
members will have minimum or no co-payments.
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. Pneumonia vaccines: Bestmed identifies high-risk members, who receive a letter to advise them that they are
The treatment programme covered by the Scheme is based on the HIV/AIDS funding guideline and approved eligible for a pneumonia vaccination.
treatment depends on the clinical parameters of each individual. The stage of the disease and the results of
Paediatric immunisations: Bestmed reimburses vaccines for children as listed on the Department of Health
blood tests determine what treatment will be covered and how the individual must be followed up. Cover is also
vaccine schedule on all Bestmed options, except for Beat1.
provided for mother–to–child transmission in pregnancy and as post–exposure prophylaxis.
Back and neck preventative treatment: Documentation Based Care (DBC) and workability are providers for
Details can be obtained by contacting LifeSense Managed Care, using the contact details provided on the back
Bestmed’s back and neck treatment programme.
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. 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.
Dialysis Care The principles applied are those of analysing, correcting and maintaining correct body posture as well as
stabilisation of the spine.
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. All members are eligible for this benefit. For a member to register on the programme he/she needs to visit a DBC
Medicines that are used in end-stage renal disease are only covered when the Scheme funding guidelines are or Workability clinic and have an assessment done by the clinic who will then motivate if the member qualifies for
met. Bestmed has appointed National Renal Care (NRC) as Designated Service Provider (DSP) for renal dialysis this programme. The member can thereafter send the application to Bestmed for authorisation.
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 Bestmed Comparative Guide 2018 7
Haemophilus influenzae Type B vaccine (HIB titre): This vaccine is administered in the prevention of illnesses Maternity Care
that are caused by this bacterium – most commonly bacteremia, pneumonia, epiglottitis, bacterial meningitis.
Our Maternity Care programme is designed to give you information and support during your pregnancy.
Human papillomavirus vaccine (HPV): The HPV vaccination is administered to assist in the prevention of
Registering on this programme will give you the following support and benefits:
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. • A 24-hour help line.
Female contraceptives: All females of child-bearing age qualify for female contraceptives to the value of R1 • Weekly e-mails with helpful tips about your pregnancy, your baby’s development and how to deal with
950 per family per year. unpleasant pregnancy symptoms.
• During your pregnancy you will receive a welcome pack and other small surprises:
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. • Baby bag.
General and option-specific exclusions may apply. • Pregnancy guide.
Mammogram: All females 40 years and older qualify for a mammogram. Please note that protocols as well as • Discount vouchers.
general and option-specific exclusions may apply. Please refer to www.bestmed.co.za for more details. • Various baby items.
Pap smear: All females 18 years and older qualify for a pap smear. Please note that protocols as well as general • Register on the Maternity Care programme simply by sending an e-mail to
and option-specific exclusions may apply. Please refer to www.bestmed.co.za for more details. 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.
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.
Wellness 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 on-site 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 Wellness Programme 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. Bestmed is the
only Scheme that
Baby growth assessments: Each beneficiary ages 0 months to 35 months will qualify for three consultations
covers midwife-
at a Bestmed contracted pharmacy clinic per year. During these consultations the baby’s height and weight will
assisted births
be measured and captured in order to monitor the child’s health and development. This new offering will replace
at 100% of
the Infant Care programme.
Scheme tariff, on
Based on the results received from all the contracted providers doing the assessments, families will be able all options.
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 Wellness programme, please send an email to
wellness@bestmed.co.za or fax to 012 472 6787.
8 Bestmed Comparative Guide 2018 Bestmed Comparative Guide 2018 9
Method of Scheme benefit payment
Beat1 Beat2 Beat3 Beat4
Beat
• 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
The Beat range offers per family. per family.
flexible hospital benefits
with limited savings on
some options to pay for
out-of-hospital expenses.
This range is ideal for the The Non-Network option provides
you with access to any hospital of
young, active and starting your choice. This is the standard
out. Beat1, 2 and 3 also option.
offer you the decision The Network option provides you
to lower your monthly with a list of designated hospitals
for you to use and also saves on
contribution in the form your monthly contribution.
Are you scheduled
of a Network option. for a medical
procedure in the
near future? Be
sure to obtain pre-
authorisation before
you go.
Bestmed Comparative Guide 2018 11
In-hospital benefits (continued) Out-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
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
Beat1 Beat2 Beat3 Beat4
payments apply) family. per family.
Overall day-to-day limit Not applicable. M = R10 800, M1+ = R21 600.
Beat
Beat
Prosthesis – Internal Sub-limits per beneficiary: Sub-limits per beneficiary: Sub-limits per beneficiary:
Family Practitioner (FP) and No benefit. Savings first. FP and specialist consultations only at Savings first.
• *Functional limited to R11 880. • *Functional limited to • *Functional limited to
Note: Sub-limit subject to R11 880. R14 300. specialist consultations Bestmed DSPs at network tariffs. Limited to M = R2 750,
• Vascular R26 500.
the above prosthesis limit. M1+ = R4 900. (Subject to overall
• Pacemaker (dual chamber) R36 200. • Vascular R26 600. • Vascular R28 300.
day-to-day limit)
*Functional: Items utilised • Endovascular and catheter-based procedures - no • Pacemaker (dual • Pacemaker (dual
chamber) R36 200. chamber) R47 400. Basic and specialised dentistry No benefit. Basic: Preventative benefit or savings account. Savings first.
towards treating or supporting benefit.
• Endovascular and • Endovascular and Specialised: Savings account. Limited to M = R4 650,
a bodily function • Spinal R26 500.
catheter-based catheter-based Orthodontic: Subject to pre-authorisation. M1+ = R9 340. (Subject to overall
• Artificial disk - no benefit. procedures - no benefit. procedures - no benefit. day-to-day limit). Orthodontics
• Drug-eluting stents - no benefit. • Spinal R26 600. • Spinal R28 300. are subject to pre-authorisation.
• Mesh R9 300. • Artificial disk - no • Artificial disk - Medical aids, apparatus and No benefit. Savings account. Savings first. 100% Scheme
• Gynaecology/Urology R7 600. benefit. no benefit. appliances including wheelchairs tariff. Limited to R9 700 per
• Lens implants R5 800 per lens. • Drug-eluting stents - no • Drug-eluting stents and hearing aids family. (Subject to overall
benefit. R15 900. day-to-day limit)
• Mesh R9 350. • Mesh R10 500. Supplementary services No benefit. Savings account. Savings first.
• Gynaecology/Urology • Gynaecology/Urology Limited to M = R4 200,
R7 720. R7 700. M1+ = R8 530. (Subject to overall
• Lens implants R5 800 • Lens implants R6 000 day-to-day limit)
per lens. per lens. 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
Prosthesis – External No benefit Limited to R19 700 wound therapy treatment and family. (Subject to overall
per family. related nursing services - out-of- day-to-day limit)
Exclusions (Prosthesis Joint replacement surgery (except for PMBs). Joint replacement surgery Joint replacement surgery hospital)
sub-limit subject to preferred PMBs subject to prosthesis limits: (except for PMBs). (except for PMBs). Optometry benefit No benefit. Savings account. Consultation R365.
provider, otherwise limits and PMBs subject to prosthesis PMBs subject to prosthesis (PPN capitation provider) Frame R550 AND
• Hip replacement and other major joints R27 900.
co-payments apply) limits: limits: Single-vision lenses R175 OR
• Knee replacement R34 400. • Hip replacement and • Hip replacement and
Bifocal lenses R380 OR
• Minor joints R10 700. other major joints other major joints
R28 100. R29 100. Multifocal lenses R695.
• Knee replacement • Knee replacement Contact lenses R1 420
R34 770. R38 660. Diagnostic imaging No benefit. Savings account. Savings first.
• Other minor joints • Other minor joints and pathology Limited to M = R2 750,
R10 700. R11 880. M1+ = R5 600. (Subject to overall
Orthopaedic and medical appliances 100% Scheme tariff. day-to-day limit)
Pathology 100% Scheme tariff. 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.
Diagnostic imaging 100% Scheme tariff.
family.
Specialised diagnostic imaging 100% Scheme tariff. Subject to co-payments. 100% Scheme tariff.
Oncology Oncology programme - make use of Independent Clinical Oncology Network (ICON) as the DSP.
Confinements 100% Scheme tariff.
Maternity benefits No benefit. Savings account. 100% Scheme tariff.
Refractive surgery No benefit. 100% Scheme tariff. 100% Scheme tariff. 2 sonars and up to 12 antenatal consultations.
Subject to pre- Subject to pre-authorisation
Rehabilitation services No benefit. Savings account. Vested savings.
authorisation and protocols. and protocols. Limited to
after trauma
Limited to R7 000 per eye. R7 900 per eye.
Peritoneal dialysis and Subject to pre-authorisation. DSP network applicable.
Midwife-assisted births 100% Scheme tariff.
haemodialysis
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 2018 Bestmed Comparative Guide 2018 13
Medicine Contributions
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
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. Non-Network (NN)/
NN N NN N NN N NN
Note: Refer to the Chronic Conditions List at the back of the Comparative Guide. Network (N)
Risk R1 363 R1 226 R1 398 R1 259 R2 123 R1 909 R3 334
Beat1 Beat2 Beat3 Beat4
Beat
Beat
PRINCIPAL MEMBER Savings R0 R0 R287 R258 R435 R392 R588
CDL & PMB chronic medicine 100% Scheme tariff. Co-payment of 40% for non-formulary medicine. 100% Scheme tariff. Total R1 363 R1 226 R1 685 R1 517 R2 558 R2 301 R3 922
Co-payment of 30% for
Risk R1 058 R953 R1 087 R978 R1 508 R1 358 R2 753
non-formulary medicine.
ADULT DEPENDANT Savings R0 R0 R223 R200 R309 R278 R486
Non-CDL chronic medicine No benefit. 5 conditions. 9 conditions.
75% Scheme tariff. Limited to 85% Scheme tariff. Limited to Total R1 058 R953 R1 310 R1 178 R1 817 R1 636 R3 239
M = R2 900, M1+ = R5 900. M = R6 370, M1+ = R12 740. Risk R573 R516 R589 R530 R819 R738 R824
Co-payment of 40% for Co-payment of 30% for
CHILD DEPENDANT Savings R0 R0 R121 R109 R168 R151 R146
non-formulary medicine. non-formulary medicine.
Total R573 R516 R710 R639 R987 R889 R970
Biologicals and other No benefit.
high-cost medicine Maximum contribution 4
child dependants*
Acute medicine No benefit. Savings account. Savings first. Limited to
M = R2 430, M1+ = R4 910. Recognition of a child Under 21, unless a registered student.
(Subject to overall dependant
day-to-day limit)
Over-the-counter (OTC) medicine No benefit. Savings account. *Member choice: 1. R550 OTC * You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.
See benefit option rules limit OR 2. Access to full PMSA
for OTC purchases (after R550 Abbreviations
limit) = self-payment gap CDL = Chronic Disease List; DBC = Documentation Based Care (back rehabilitation programme); DSP = Designated Service Provider;
accumulation. FP = Family Practitioner or Doctor; Wellness Programme = 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;
*The default OTC choice is 1. R550 OTC limit. Members wishing to choose the other option are welcome to contact Bestmed. 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
Preventative care benefits 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
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP). 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.
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
Wellness Programme • 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 2018 Bestmed Comparative Guide 2018 15
Method of Scheme benefit payment
Pace1 Pace2 Pace3 Pace4
Pace
• 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
The Pace range offers *Functional: Items utilised
chamber) R47 300. chamber) R52 750. chamber) R52 750. chamber) R52 750.
towards treating or supporting
more comprehensive in- a bodily function • Endovascular and • Spinal R36 600. • Spinal R36 700. • Spinal R42 000.
catheter-based
hospital and out-of-hospital procedures - no benefit.
• Artificial disk R16 000. • Artificial disk • Artificial disk R18 850.
• Drug-eluting stents R16 000. • Drug-eluting stents
benefits. These options • Spinal R27 700. R16 000. • Drug-eluting stents R18 850.
all have additional savings • Artificial disk - no benefit. • Mesh R16 000. R16 000. • Mesh R16 600.
accounts to cover extensive • Drug-eluting stents - • Gynaecology/Urology • Mesh R16 000. • Gynaecology/Urology
no benefit. R11 950. • Gynaecology/Urology R13 700.
out-of-hospital expenses.
• Mesh R10 400. • Lens implants R10 260 R12 000. • Lens implants R15 170
This range is ideal for • Gynaecology/Urology per lens. • Lens implants per lens.
families and those seeking R7 500. • Joint replacements: R10 260 per lens. • Joint replacements:
• Lens implants R5 700 • Joint replacements:
comprehensive cover. per lens.
1. Hip replacement and 1. Hip replacement and
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 17
Generic medicines
Out-of-hospital benefits
are always available Note: Benefits mentioned below are subject to Scheme tariff, and may also be subject to pre-authorisation and clinical protocols.
at a lower cost than
the original brand and
are just as effective. Pace1 Pace2 Pace3 Pace4
Bestmed recommends Overall day-to-day limit M = R9 180, M = R12 960, M = R16 200, M = R30 200,
using these generic M1+ = R18 360. M1+ = R25 920. M1+ = R33 480. M1+ = R48 700.
alternatives to avoid
incurring additional FP and specialist Savings first. Savings first. Savings first. Limited to M = R4 750,
costs. 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,
Did you know overall day-to-day limit) overall day-to-day limit) M1+ = R11 450. (Subject to
overall day-to-day limit)
that Bestmed’s
Medical aids, apparatus Savings first. 100% Scheme Savings first. 100% Scheme Savings first. 100% Scheme 100% Scheme tariff. Limited
Pace option range 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
does not have 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).
co-payment or
automatic self- 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
payment gaps? 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
In-hospital benefits (continued)
Pace
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
Pace1 Pace2 Pace3 Pace4
M1+ = R7 700. (Subject to M1+ = R9 350. (Subject to M1+ = R4 750. (Subject to overall day-to-day limit)
Prosthesis – External Limited to R19 300 Limited to R23 000 Limited to R23 100 Limited to R26 100 overall day-to-day limit) overall day-to-day limit) overall day-to-day limit)
per family. per family. per family. per family.
Exclusions (Prosthesis Joint replacement surgery Not applicable. Wound care benefit Savings first. 100% Scheme Savings first. 100% Scheme Savings first. 100% Scheme Limited to R11 600 per
sub-limit subject to preferred (except for PMBs). PMBs (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
provider, otherwise limits and subject to prosthesis limits: pressure wound therapy family. (Subject to overall family. (Subject to overall family. (Subject to overall day-to-day limit)
co-payments apply) • Hip replacement and treatment and related day-to-day limit) day-to-day limit) day-to-day limit)
other major joints nursing services - out-of-
R28 200. hospital)
• Knee replacement
Optometry benefit Consultation R365 Consultation R365 Consultation R365 Consultation R365
R37 500.
(PPN capitation provider) Frame R550 AND Frame R550 AND Frame R550 AND Frame R550 AND
• Minor joints R11 650.
Single vision lenses R175 OR Single vision lenses Single vision lenses Single vision lenses
Orthopaedic and medical 100% Scheme tariff. Bifocal lenses R380 OR R175 OR R175 OR R175 OR
appliances Multifocal lenses R695 Bifocal lenses R380 OR Bifocal lenses R380 OR Bifocal lenses R380 OR
Pathology 100% Scheme tariff. 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 100% Scheme tariff.
Diagnostic imaging Savings first. 100% Scheme Savings first. 100% Scheme Savings first. 100% Scheme 100% Scheme tariff. Limited
Specialised diagnostic imaging 100% Scheme tariff. 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.
Confinements 100% Scheme tariff. 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)
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 Maternity benefits 100% Scheme tariff. 2 sonars and up to 12 antenatal consultations.
per eye.
Specialised diagnostic 100% Scheme tariff. MRI/CT scans: Maximum of 3 scans per beneficiary.
Midwife-assisted births 100% Scheme tariff.
imaging Limited to R12 300 per family. PET scan: 1 scan per beneficiary. 100% Scheme tariff.
Supplementary services 100% Scheme tariff.
Rehabilitation services Vested savings. 100% Scheme tariff.
Alternatives to hospitalisation 100% Scheme tariff. after trauma
Emergency evacuation 100% Scheme tariff. Pre-authorised and rendered by ER24. Oncology Oncology programme - make use of Independent Clinical Oncology Network (ICON) as the DSP.
Co-payments Not applicable.
Peritoneal dialysis and Subject to pre-authorisation. DSP network applicable.
haemodialysis
18 Bestmed Comparative Guide 2018 Bestmed Comparative Guide 2018 19Medicine Contributions
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
Pace1 Pace2 Pace3 Pace4
medicine will be unlimited from Scheme risk. Risk R2 650 R3 976 R4 565 R6 410
Note: Refer to the Chronic Conditions List at the back of the Comparative Guide.
PRINCIPAL MEMBER Savings R662 R701 R805 R198
Total R3 312 R4 677 R5 370 R6 608
Pace1 Pace2 Pace3 Pace4
Risk R1 860 R3 898 R3 674 R6 410
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 ADULT DEPENDANT Savings R465 R688 R648 R198
non-formulary medicine. non-formulary medicine. non-formulary medicine. non-formulary medicine. Total R2 325 R4 586 R4 322 R6 608
Non-CDL chronic 7 conditions. 18 conditions. 19 conditions. 26 conditions. Risk R669 R876 R784 R1 502
medicine 85% Scheme tariff. 85% Scheme tariff. 85% Scheme tariff. 85% Scheme tariff.
CHILD DEPENDANT Savings R167 R155 R139 R46
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. Total R836 R1 031 R923 R1 548
Co-payment of 35% for Co-payment of 30% for Co-payment of 25% for Co-payment of 20% for
Maximum contribution
non-formulary medicine. non-formulary medicine. non-formulary medicine. non-formulary medicine. 4
child dependant*
Biologicals and other No benefit. Limited to R140 000 Limited to R280 000 Limited to R414 400
Recognition of a child Under 21, unless a registered student.
high-cost medicine per beneficiary. per beneficiary. per beneficiary.
dependant
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). *You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.
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. Abbreviations
See benefit option rules DBC = Documentation Based Care (Back Rehabilitation Programme); DSP = Designated Service Provider; FP = Family Practitioner or
Doctor; Wellness Programme = 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
*The default OTC choice is 1. R550 OTC limit. Members wishing to choose the other option are welcome to contact Bestmed.
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
Preventative care benefits 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
Pace
Pace
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)
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP).
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.
Pace1 Pace2 Pace3 Pace4 Please visit www.bestmed.co.za for the complete liability and responsibility disclaimer for Bestmed Medical Scheme as well as our terms and conditions.
Preventative care • Flu vaccines. • Flu vaccines.
• Pneumonia vaccines. • Pneumonia vaccines.
Note: Refer to Scheme
• Paediatric immunisations. • Paediatric immunisations.
rules for funding
• Female contraceptives – • Female contraceptives – R1 950 per family per year.
criteria applicable to each
R1 950 per family per year.
preventative
• DBC programme.
• DBC programme.
Chat to us directly
care benefit. • Preventative dentistry. (incl. gloves and sterile equipment).
• Preventative dentistry. • Haemophilus influenzae Type B vaccine. (HIB). using our Chat
(incl. gloves and sterile
equipment). • Mammogram.
Now service on the
• Haemophilus influenzae • PSA screening - ages 50 and above, every 24 months.
Type B vaccine. (HIB). • HPV vaccines. Bestmed website.
• Mammogram. • Bone densitometry.
• HPV vaccines. • Pap smear – ages 18 and above, every 24 months.
• Pap smear – age 18 and
above, every 24 months.
Wellness Programme • 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 Medicine formulary – This is a
Note: Biometric
• Occupational therapy assessment - 1 per beneficiary per year (ages 3-12 years) list of prescription medicines
screening activates
(both generic and brand name)
the other assessment • Baby growth assessment at a contracted pharmacy clinic - 3 per beneficiary per year (ages 0-35 months)
for which the Scheme will
benefits.
pay. Make sure you familiarise
yourself with this list when
Disclaimer on exclusions: General and option specific exclusions apply. Please refer to www.bestmed.co.za for more details. doctors prescribe medicine to
you.
20 Bestmed Comparative Guide 2018 Bestmed Comparative Guide 2018 21Method of Scheme benefit payment
Pulse1 Pulse2
Pulse
• 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.
The Pulse range is ideally • Mesh R15 200.
• Drug-eluting stents - no benefit. • Gynaecology/Urology R11 300.
suitable for you if: • Mesh R8 100. • Lens implants R9 700 per lens.
• You are seeking a plan option • Gynaecology/Urology R6 690. • Joint replacements:
that is based on your income. • Lens implants R4 650 per lens. 1. Hip replacement and other major joints
R41 400.
• You are comfortable with 2. Knee replacement R48 350.
making use of designated 3. Minor joints R18 000.
service providers (DSPs) Prosthesis – External No benefit. Limited to R21 600 per family.
within our network. Exclusions (Prosthesis sub-limit subject to Joint replacement surgery (except for PMBs). Not applicable.
preferred provider, otherwise limits and PMBs subject to prosthesis limits:
• You are looking for unlimited
co-payments apply) • Hip replacement and other major joints R22 700.
comprehensive cover for • Knee replacement R28 700.
hospitalisation and the added • Minor joints R10 750.
benefit of preventative care. 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.
Confinements 100% Scheme tariff.
Refractive surgery No benefit. 100% Scheme tariff. Limited to R7 950 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.
Bestmed Comparative Guide 2018 23You can also read
