Comparative Guide 2021 - Aon
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Comparative Guide 2021
1 151 5 509
REGISTERED
MOMS ON MEMBERS ON
THE BESTMED THE BESTMED
MATERNITY ONCOLOGY
PROGRAMME PROGRAMME
7 799 967
MEMBERS REGISTERED ON
THE BESTMED DIABETIC BESTMED
PROGRAMME BABIES BORN
2 130 ALL DATA AS AT 31 JULY 2020
MEMBERS DID
PERSONALLY YOURS 3 Medicine 15
FREE HEALTH
RISK ASSESSMENTS Why do so many people choose Bestmed? 3 Preventative care benefits 16
All you need to know about Bestmed Tempo 4 Contributions 17
5 077
BEAT 5 PULSE 17
Method of Scheme benefit payment 6 Method of Scheme benefit payment 18
In-hospital benefits 6 In-hospital benefits 18
Out-of-hospital benefits 8 Out-of-hospital benefits 19
MEMBERS REGISTERED ON
THE BESTMED HIV/AIDS Medicine 9 Medicine 20
PROGRAMME
Preventative care benefits 10 Preventative care benefits 21
Contributions 11 Contributions 21
203 332 PACE 12
When do co-payments apply?
Out-of-hospital radiology and ultrasounds per option
22
22
Method of Scheme benefit payment 12
In-hospital benefits 12 CHRONIC DISEASE LIST 23
Out-of-hospital benefits 14
2 COMPARATIVE GUIDE 2021
Why do so many people choose Bestmed?
An extensive service provider network
More than 4 200 family practitioners in Bestmed’s network.
Relevancy is the new currency
More than 2 600 specialists on Bestmed’s network.
Bestmed has 13 structured plans designed to suit e
very life stage and More than 15 800 network provider agreements.
pocket. Country-wide geographical network coverage.
No automatic self-payment gaps on any option.
Excellent preventative care benefits on all o
ptions, including pneumonia
A leading health and wellness programme, Bestmed
and flu vaccines, f emale contraceptives, paediatric immunisations, a
back Tempo, at no additional cost
and neck preventative programme, HPV v
accinations for females 9 to 26
An established network of healthcare professionals supporting your physical and
years old, and a m
ammogram every 24 months for females older than 40.
mental wellbeing.
Students are eligible for child dependant rates up to 26 years of age. Fully funded fitness assessments at biokineticists.
Extensive maternity benefits, including a maternity care programme. Fully funded dietitian consults to assess and improve your eating habits.
Disease management support programmes include diabetes (HaloCare), Health checks and screenings at our nationwide pharmacy network.
oncology and HIV/AIDS programmes. Includes family interventions, family workshops, vaccinations and baby growth
assessments.
Excellence that is Personally Yours
Be ‘appy’
Bestmed has been offering medical aid for 56 y
ears.
A digital version of your membership card.
Bestmed is the largest self-administered scheme which means that Find a service provider.
administration costs are less than our competitors.
Submit a claim.
We are the fourth largest open medical scheme in the country. Check your available benefits.
Single digit increases over 3 consecutive years. Email your membership card to service
providers.
Four of our options have been selected as the best performers within the
Check your Health Risk Assessment results.
South African medical scheme market (2018 GTC Medical Aid Survey).
Submit a referral. Let others share in the
Bestmed has been voted third on the client s ervice satisfaction benefits of Bestmed membership.
benchmark by the Ask Afrika Orange Index 2019. Update contact details for dependants
Bestmed has a strong solvency ratio of 35.4% as at 31 December 2019. 18 yrs and older for “Personally Yours”
experience.
203 332 lives under Bestmed’s care.
Submit your chronic application/prescription.
COMPARATIVE GUIDE 2021 3
All you need to know about Bestmed Tempo
WHAT IS BESTMED TEMPO?
Bestmed Tempo is our health and wellness programme that assists members in leading a
healthier lifestyle and living their best lives.
WHY SHOULD I ACTIVATE BESTMED TEMPO?
As a member, you and your family already have access to the Bestmed Tempo benefits at
no additional costs. The wellness programme is available regardless of which one of the 13
Bestmed benefit options you may have chosen. By simply activating Bestmed Tempo, you
will automatically have access to over a thousand healthcare professionals who are trained
and motivated to help you improve your lifestyle and become the best version of yourself.
HOW DO I ACTIVATE THE PROGRAMME?
All you need to do is complete the Bestmed Tempo Health Assessment (previously HRA) at
any one of our nationwide network of pharmacy clinics, or at your company’s wellness day.
The assessment will not only give you an important view of your health status, but it will
also unlock all of the health benefits of the Bestmed Tempo wellness programme.
WHAT ARE THE BENEFITS OF THE BESTMED TEMPO WELLNESS PROGRAMME?
The Bestmed Tempo wellness programme is focused on supporting you on your path to
improving your health and realising the rewards that come with it. To ensure you achieve
this, you will have access to the following benefits:
• Bestmed Tempo Health Assessment (previously HRA) for adults which includes:
- The Bestmed Tempo lifestyle questionnaire
- Blood pressure check
Set your TEMPO - Cholesterol check
with a FREE - Glucose check
- HIV screening
Health - Height, weight and waist circumference
Assessment, • Bestmed Tempo Child Health Assessments:
not a smoothie! - Ages 13-17 years: Assessment performed by a Bestmed Tempo partner biokineticist
(1 per beneficiary per year)
- Ages 3-12 years: Assessment performed by a Bestmed Tempo partner occupational
therapist (1 per beneficiary per year)
4 COMPARATIVE GUIDE 2021
- Ages 0-2 years: Baby growth and development assessments done at a Bestmed
Tempo partner pharmacy clinic – 3 assessments per year
• Bestmed Tempo Nutrition Assessment:
- Family nutritional assessment at a Bestmed Tempo partner dietitian (1 assessment
per family per year).
• Bestmed Tempo Fitness and Nutrition programmes (beneficiaries 18 and older):
- 3 personalised consultations with a Bestmed Tempo partner biokineticist BEAT
- 3 personalised consultations with a Bestmed Tempo partner dietitian
• Bestmed Tempo Group classes:
- A range of group classes throughout the year to help encourage and support a
healthier lifestyle regardless of your age or health status
DO THE FREE BENEFITS DIFFER FOR MEMBERS ON DIFFERENT HEALTHCARE OPTIONS?
No. The Bestmed Tempo benefits are exactly the same on all the options.
We hope you found the answer you’re looking for but, if not, please email us for more
information: tempo@bestmed.co.za
Choose a
network option
for lower
contributions on
Beat!
COMPARATIVE GUIDE 2021 5
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 just starting out. Beat1, 2 and 3 also offer you the decision to BEAT1 BEAT2 BEAT3 BEAT4
lower your monthly contribution in the form of a Network option. Accommodation 100% Scheme tariff. 100% Scheme
(hospital stay) and tariff.
theatre fees
Method of Scheme benefit payment Take-home medicine 100% Scheme tariff. Medicine limited to 7 days.
BEAT1 BEAT2 BEAT3 BEAT4 Treatment in mental 100% Scheme tariff. Limited to 21 days per beneficiary.
health clinics
• In-hospital benefits are • In-hospital benefits are • In-hospital benefits are • In-hospital benefits are
paid from Scheme risk. paid from Scheme risk. paid from Scheme risk. paid from Scheme risk. Treatment of 100% Scheme tariff. Limited to 21 days or R32 299 per beneficiary. Subject to
• Some preventative care • Some preventative care • Some out-of-hospital • Some out-of-hospital chemical and network facilities.
benefits are available benefits are available benefits are paid from benefits are paid from substance abuse
from Scheme risk. from Scheme risk. Scheme risk and some your medical savings Consultations and 100% Scheme tariff.
• Out-of-hospital benefits • Out-of-hospital benefits from your medical account first, once procedures
are paid from your own are paid from your savings account. depleted, from your day-
pocket. medical savings account. • Some preventative care to-day benefit. Surgical procedures 100% Scheme tariff.
benefits are available • Some preventative care and anaesthetics
from Scheme risk. benefits are available Organ transplants 100% Scheme tariff (PMBs only).
from Scheme risk.
Major medical No benefit. 100% Scheme 100% Scheme
• Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs, this will not maxillofacial surgery (PMBs only at DSP day hospitals). tariff. Limited to tariff. Limited to
affect your savings (annual or vested) for applicable options. strictly related to R12 944 per R13 181 per family.
certain conditions family.
BEAT NETWORK PLAN OPTION Dental and oral PMBs only at DSP Qualifying PMB Limited to Limited to
surgery day hospitals. procedures only at R8 075 per family. R10 094 per family.
• Bestmed offers members a choice of network hospitals for in-hospital benefits. (In- or out of DSP day hospitals.
• If a member voluntarily chooses not to make use of a hospital within the Beat network, a maximum co-payment of hospital) Pulp procedures,
extractions and
R11 874 will apply.
restorations in
DSP day hospitals
(only disabled
In-hospital benefits beneficiaries
and beneficiaries
The Non-Network option provides you with access to any hospital of your choice. This is the standard option. The aged 0 – 7 years) –
Network option provides you with a list of designated hospitals for you to use and also saves on your monthly limited to R5 250
contribution. per family.
Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs, this will not Prosthesis 100% Scheme tariff. 100% Scheme 100% Scheme
affect your savings. (subject to preferred Limited to R78 846 per family. tariff. Limited to tariff. Limited to
providers and DSPs, R79 678 per family R97 260 per family.
otherwise limits and
Note: Benefits mentioned below are subject to pre-authorisation and clinical protocols.
co-payments apply)
Members are required to obtain pre-authorisation for all planned procedures at least 14 (fourteen) days before the
Prosthesis – External No benefit (PMBs only). Limited to R23 393
event. However, in the case of an emergency, the member, their representative or the hospital must notify Bestmed
per family.
of the member’s hospitalisation as soon as possible or on the first working day after admission to hospital.
6 COMPARATIVE GUIDE 2021
BEAT1 BEAT2 BEAT3 BEAT4 BEAT1 BEAT2 BEAT3 BEAT4
Prosthesis – Internal Sub-limits per beneficiary: Sub-limits per Sub-limits per Specialised 100% Scheme tariff. Subject to co-payments. 100% Scheme
• *Functional limited to R14 106. beneficiary: beneficiary: diagnostic imaging tariff.
Note: Sub-limit • Vascular R31 470. • *Functional • *Functional (Including MRI scans,
subject to overall • Pacemaker (dual chamber) limited to limited to CT scans and isotope
annual prosthesis R42 986. R14 107. R16 981. studies. PET scans
limit. • Endovascular and catheter-based • Vascular • Vascular only included as
procedures – no benefit. R31 586. R33 605. indicated per option)
*Functional: • Spinal R31 470. • Pacemaker • Pacemaker
Oncology 100% Scheme tariff. Subject to pre-authorisation and DSPs.
Items utilised • Artificial disk – no benefit. (dual chamber) (dual chamber)
towards treating or • Drug-eluting stents – PMBs and DSP R42 986. R56 285. Mammary surgery No benefit for reconstructive surgery (which may include symmetrising, partial
supporting a bodily products only. • Endovascular and • Endovascular and (Breast cancer or total mastectomy etc.) on the unaffected (non-cancerous) breast of a breast
function. • Mesh R11 044. catheter-based catheter-based patient) cancer patient.
• Gynaecology/Urology R9 025. procedures – no procedures –
Peritoneal dialysis 100% Scheme tariff. Subject to pre-authorisation and DSPs.
• Lens implants R6 887 a lens per eye. benefit. no benefit.
and haemodialysis
• Spinal R31 586. • Spinal R33 605.
• Artificial disk – no • Artificial disk – Confinements 100% Scheme tariff.
benefit. no benefit. (Birthing)
• Drug-eluting • Drug-eluting HIV/AIDS 100% Scheme tariff. Subject to pre-authorisation and DSPs..
stents – PMBs stents R18 881.
and DSP products • Mesh R12 469. Refractive surgery PMBs only. 100% Scheme 100% Scheme
only. • Gynaecology/ and all types of tariff. Subject to tariff. Subject to
• Mesh R11 101. Urology R9 144. procedures to pre-authorisation pre-authorisation
• Gynaecology/ • Lens implants improve or stabilise and protocols. and protocols.
Urology R9 168. R7 125 a lens per vision (except Limited to R8 312 Limited to R9 381
• Lens implants eye. cataracts) per eye. per eye.
R6 887 a lens Midwife-assisted 100% Scheme tariff.
per eye. births
Exclusions Joint replacement surgery Joint replacement Joint replacement Supplementary 100% Scheme tariff.
(Prosthesis sub-limit (except for PMBs). surgery (except for surgery (except for services
subject to preferred PMBs). PMBs).
PMBs subject to prosthesis limits: Alternatives to 100% Scheme tariff.
provider, otherwise
• Hip replacement and other major joints PMBs subject to hospitalisation
limits and co- PMBs subject to
R33 130. prosthesis limits:
payments apply) prosthesis limits: Palliative care and 100% Scheme tariff. Limited to R8 000 per month, over 3 100% Scheme
• Knee replacement R40 848. • Hip replacement
• Hip replacement Home-based care in months. Total benefit limited to R24 000. Subject to pre- tariff. Limited
• Minor joints R12 706. and other major
and other major lieu of hospitalisation authorisation and DSPs. to R10 000 per
joints R34 555.
joints R33 368. month, over 3
• Knee replacement
• Knee months. Total
R45 907.
replacement benefit limited
• Other minor joints
R41 288. to R30 000.
R14 106.
• Other minor joints Subject to pre-
R12 706. authorisation and
DSPs.
Orthopaedic and 100% Scheme tariff.
medical appliances Emergency Services rendered by ER24.
evacuation
Pathology 100% Scheme tariff.
Day procedures at a Day procedures at a day-hospital facility funded at 100% Scheme tariff. Subject to
Basic radiology 100% Scheme tariff. day-hospital facility pre-authorisation. DSPs apply for PMBs
International travel Up to R10 million and a maximum of 90 days. Services rendered by Bryte Insurance
cover and managed by ER24.
COMPARATIVE GUIDE 2021 7
BEAT1 BEAT2 BEAT3 BEAT4 BEAT1 BEAT2 BEAT3 BEAT4
Co-payments Co-payment of R3 800 on all Co-payment of Not applicable. Medical aids, apparatus No benefit. Savings account. Savings first.
endoscopic investigations and R3 800 on all and appliances 100% Scheme
specialised diagnostic imaging if done endoscopic including wheelchairs tariff. Limited
in a private hospital. Any other facility, investigations if and hearing aids to R11 519 per
no co-payment. done in a private family. (Subject
hospital. Any other (Hearing aids are subject to overall day-to-
to pre-authorisation) day limit)
facility, no co-
payment. Supplementary services No benefit. Savings account. Savings first.
Co-payment for voluntary use of non-network hospital Limited to
M = R4 987,
R11 874. For network options.
M1+ = R10 129.
(Subject to
overall day-to-
Out-of-hospital benefits day limit)
Note: Benefits below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service Wound care benefit 100% Scheme tariff. Savings first.
providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP). (incl. dressings, negative Limited to R 3 527 per family. 100% Scheme
pressure wound therapy tariff. Limited
Members are required to obtain pre-authorisation for all planned treatments and/or procedures. -NPWT- treatment and to R4 987 per
related nursing services family. (Subject
Approved PMBs will be paid from scheme risk.
-out-of-hospital) to overall
day-to-day limit)
BEAT1 BEAT2 BEAT3 BEAT4 Optometry benefit No benefit. Savings account. Benefits available every 24 months
(PPN capitation provider) from date of service.
Overall day-to-day limit Not applicable. M = R12 824,
M1+ = R25 649. Network Provider (PPN)
Consultation - 1 per beneficiary.
Family Practitioner No benefit. Savings account. Savings first.
Frame = R825 covered AND
(FP) and specialist Limited to
100% of cost of standard lenses
consultations M = R3 265,
(single vision OR bifocal OR multifocal)
M1+ = R5 818.
OR Contact lenses = R1 565
(Subject to
OR
overall day-to-
Non-network Provider
day limit)
Consultation - R350 fee at non-
Diabetes primary care 100% of Scheme tariff subject to registration with HaloCare. network provider Frame = R598 AND
consultation 2 primary care consultations at Dis-Chem Pharmacies limited to R359 per Single vision lenses = R210 OR
consultation. Bifocal lenses = R445 OR
Multifocal lenses = R770
Beat4 option: Paid first from the “FP and specialist consultations” day-to-day In lieu of glasses members can opt for
benefit, thereafter Scheme risk. contact lenses, limited to R1 565
Basic and specialised No benefit. Basic: Preventative benefit or savings Savings first. Basic radiology No benefit. Savings account. Savings first.
dentistry account. Limited to and pathology Limited to
M = R5 650, M = R3 265,
Specialised: Savings account. M1+ = M1+ = R6 650.
Orthodontic: Subject to pre- R11 349. (Subject to
authorisation. (Subject to overall day-to-
overall day- day limit)
to-day limit).
Orthodontics are
subject to pre-
authorisation.
8 COMPARATIVE GUIDE 2021
BEAT1 BEAT2 BEAT3 BEAT4 BEAT1 BEAT2 BEAT3 BEAT4
Specialised diagnostic 100% Scheme tariff. 100% Scheme 100% Scheme Acute No benefit. Savings account. Savings first.
imaging Limited to R5 343 per family, tariff. Limited tariff. Limited to medicine Limited to
(Including MRI scans, (excluding PET scans). to R11 223 per R16 981 per M = R2 885,
CT scans and isotope family (excluding family. M1+ = R5 830.
studies. PET scans only PET scans). (Subject to overall
included as indicated per day-to-day limit)
option)
Over-the- No benefit. Savings account. *Member choice:
Oncology Oncology programme at 100% of Scheme tariff. DSP available. counter (OTC) Subject to available savings. 1. R683 OTC limit
medicine OR
Peritoneal dialysis and 100% Scheme tariff. Subject to pre-authorisation and DSPs. 2. Access to full
haemodialysis Includes savings for OTC
sunscreen, purchases (after
HIV/AIDS 100% Scheme tariff. Subject to pre-authorisation and DSPs.
vitamins and R683 limit) =
Rehabilitation services No benefit. Savings account. Vested savings. minerals with self-payment gap
after trauma nappi codes accumulation.
on Scheme Subject to
formulary available savings.
Medicine
*The Default OTC choice is 1. R683 OTC limit. Members wishing to choose the other option are welcome to contact Bestmed
Note: Generic 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.
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers,
designated service providers, 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. Thereafter,
approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
Members will not incur co-payments for PMB medications that are on the formulary for which there is no generic
alternative.
Note: Refer to the Chronic Conditions List at the back of the Comparative Guide.
BEAT1 BEAT2 BEAT3 BEAT4
CDL & PMB 100% Scheme tariff. Co-payment of 40% for non-formulary 100% Scheme tariff.
chronic medicine. Co-payment of 30%
medicine for non-formulary
medicine.
Non-CDL No benefit. 5 conditions. 9 conditions.
chronic 80% Scheme tariff. 90% Scheme tariff.
medicine Limited to Limited to
M = R3 444, M = R7 564,
M1+ = R7 006. M1+ = R15 129.
Co-payment of 35% Co-payment of 25%
for non-formulary for non-formulary
medicine. medicine.
Biologicals PMBs only as per funding protocol.
and other Subject to pre-approval.
high-cost
medicine
COMPARATIVE GUIDE 2021 9
Preventative care benefits
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers,
designated service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP).
BEAT1 BEAT2 BEAT3 BEAT4
Preventative care • Flu vaccines. • Flu vaccines. • Flu vaccines.
benefits • Pneumonia • Pneumonia vaccines. • Pneumonia
vaccines. • Travel vaccines. vaccines.
Note: Refer to • Female • Paediatric immunisations. • Travel vaccines.
Scheme rules for
contraceptives – • Female contraceptives – • Paediatric
funding criteria
R2 315 per R2 315 per beneficiary per year. immunisations.
applicable to each
preventative beneficiary per • Back and neck preventative programme. • Female
care benefit. year. • Preventative dentistry. contraceptives –
• Back and neck • Pap smear – ages 18 and above, every 24 R2 315 per
preventative months. beneficiary per
programme. • HPV vaccinations. year.
• Pap smear – ages • Mammogram – ages 40 and above, every • Back and neck
18 and above, 24 months. preventative
every 24 months. • PSA Screening – ages 50 years and programme.
• HPV above, every 24 months • Preventative
vaccinations. dentistry.
• Haemophilus
influenzae Type
B vaccine (HIB).
• Mammogram.–
ages 40 and
above, every 24
months.
• HPV
vaccinations.
• PSA Screening
– ages 50 years
and above, every
24 months.
• Pap smear – ages
18 and above,
every 24 months.
Preventative
dentistry
General No benefit Once a year for members 12 years and above. Twice a year for
full-mouth members under 12 years.
examination by
a general dentist
(incl. gloves and
use of sterile
equipment)
Full-mouth intra- No benefit Once every 36 months for all ages.
oral radiographs
10 COMPARATIVE GUIDE 2021BEAT1 BEAT2 BEAT3 BEAT4 Contributions
Intra-oral No benefit Two (2) photos per year for all ages.
BEAT1 BEAT2 BEAT3 BEAT4
radiograph
Non-Network (NN) / NN N NN N NN N NN
Network (N)
Scaling and/or No benefit Twice per year for all ages.
polishing Medical Savings Account N/A 16% 16% 14%
Fluoride No benefit Twice per year for all ages. Principal Risk R1 680 R1 511 R1 725 R1 551 R2 618 R2 356 R4 190
treatment Member
Savings R0 R0 R328 R296 R499 R449 R682
Fissure sealing No benefit Up to and including 21 years. Frequency must be in accordance with
accepted protocol. Total R1 680 R1 511 R2 053 R1 847 R3 117 R2 805 R4 872
Adult Risk R1 303 R1 174 R1 339 R1 205 R1 861 R1 676 R3 461
Space No benefit Once per space during the primary and mixed denture stage. Dependant
Savings R0 R0 R255 R230 R354 R319 R563
maintainers
Total R1 303 R1 174 R1 594 R1 435 R2 215 R1 995 R4 024
Maternity 100% Scheme tariff. Subject to the 100% Scheme tariff. Subject to the
Benefits following benefits: following benefits: Child Risk R706 R636 R726 R653 R1 011 R911 R1 035
Dependant
Consultations: Consultations: Savings R0 R0 R138 R124 R192 R174 R169
• 6 antenatal consultations at a FP OR • 9 antenatal consultations at a FP OR Total R706 R636 R864 R777 R1 203 R1 085 R1 204
gynaecologist OR midwife. gynaecologist OR midwife.
Ultrasounds: • 1 post-natal consultation at a FP OR Maximum contribution
4
• 1 x 2D ultrasound scan at 1st trimester gynaecologist OR midwife. child dependants*
(between 10 to 12 weeks) at a FP OR Ultrasounds: Recognition of a child Child dependants under the age of 21 years and registered students up to the
gynaecologist OR radiologist. • 1 x 2D ultrasound scan at 1st trimester dependant age of 26 years, in accordance with the Rules, are regarded as child dependants.
• 1 x 2D ultrasound scan at 2nd trimester (between 10 to 12 weeks) at a FP OR
(between 20 to 24 weeks) at a FP OR gynaecologist OR radiologist. * You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.
gynaecologist OR radiologist. • 1 x 2D ultrasound scan at 2nd trimester
ABBREVIATIONS
(between 20 to 24 weeks) at a FP OR
CDL = Chronic Disease List; DBC = Documentation Based Care (back rehabilitation programme); DSP = Designated
gynaecologist OR radiologist.
Service Provider; FP = Family Practitioner or Doctor; TEMPO = Biometric Screenings; HIB = Haemophilus influenzae
Supplements:
Type B vaccine; HPV = Human Papilloma Virus; M = Member; M1+ = Member and family; MRP = Mediscor Reference
• Any item categorised as a maternity
Price; PMB = Prescribed Minimum Benefit; PPN = Preferred Provider Negotiators; PSA = Prostate Specific Antigen.
supplement can be claimed up to a
maximum of R100 per claim, once a
month, for a maximum of 9 months..
Disclaimer on exclusions: General and option-specific exclusions apply. Please refer to www.bestmed.co.za for more details.
Chat to us
directly
using our Chat
Now service on
the Bestmed
website.
COMPARATIVE GUIDE 2021 11The Pace range offers more comprehensive in-hospital and out-of-hospital benefits. These options all have
additional day-to-day benefits 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 benefits are paid from Scheme risk benefit. Some • In-hospital benefits, out-of-hospital
PACE out-of-hospital benefits are paid from the annual savings first
and once depleted will be paid from the day-to-day benefit.
benefits and preventative care
benefits are paid from Scheme risk.
• Once the day-to-day benefit is depleted, benefits can be paid • Once out-of-hospital risk benefits are
from the available vested savings. Some preventative care depleted, further claims will be paid
benefits are available from Scheme risk benefit. from savings.
• Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs, this will
not affect your savings (annual or vested).
In-hospital benefits
Note: All benefits mentioned below are subject to pre-authorisation, clinical protocols and funding guidelines.
Members are required to obtain pre-authorisation for all planned procedures at least 14 (fourteen) days before the
event. However, in the case of an emergency, the member, their representative or the hospital must notify Bestmed
of the member’s hospitalisation as soon as possible or on the first working day after admission to hospital.
Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs, this will not
affect your savings.
PACE1 PACE2 PACE3 PACE4
Accommodation 100% Scheme tariff.
(hospital stay) and
theatre fees
Take-home 100% Scheme tariff. Medicine limited to 7 days.
medicine
Did you know that Treatment in 100% Scheme tariff. Limited to 21 days per beneficiary.
Bestmed’s Pace mental health
clinics
option range does Treatment of 100% Scheme tariff.
not have co-payment chemical and
substance abuse
Limited to 21 days or R32 299 per beneficiary. Subject to network facilities.
or automatic self- Consultations and 100% Scheme tariff.
procedures
payment gaps?
Surgical 100% Scheme tariff.
procedures and
anaesthetics
Organ transplants 100% Scheme tariff. (PMBs only)PACE1 PACE2 PACE3 PACE4 PACE1 PACE2 PACE3 PACE4
Major medical 100% Scheme 100% Scheme tariff. Exclusions Joint replacement Not applicable.
maxillofacial tariff. Limited to (Prosthesis surgery (except for
surgery strictly R13 062 per sub-limit subject to PMBs).
related to certain family. preferred provider, PMBs subject to
conditions otherwise limits prosthesis limits:
and co-payments • Hip replacement
Dental and oral Limited to Limited to Limited to Limited to apply) and other major
surgery (In- or out R8 075 per family. R13 419 per family. R16 862 per family. R20 187 per family.
of hospital) joints R33 486.
• Knee
Overall annual 100% Scheme 100% Scheme 100% Scheme tariff. 100% Scheme replacement
prosthesis limit tariff. Limited to tariff. Limited to Limited to tariff. Limited to R44 530.
(subject to R90 246 per R115 895 per R116 489 per R134 419 per • Minor joints
preferred provider, family. family. family. family.
R13 834.
otherwise limits
and co-payments Orthopaedic and 100% Scheme tariff.
apply) medical appliances
Prosthesis – Sub-limits per Sub-limits per Sub-limits per Sub-limits per Pathology 100% Scheme tariff.
Internal beneficiary: beneficiary: beneficiary: beneficiary:
• *Functional • *Functional • *Functional • *Functional Basic radiology 100% Scheme tariff.
Note: Sub-limit limited to limited to limited to limited to
subject to overall Specialised 100% Scheme tariff.
R16 209. R17 634. R18 999. R19 712. diagnostic imaging
annual prosthesis
• Vascular • Vascular • Vascular • Vascular (Including MRI
limit.
R32 892. R43 460. R43 580. R49 873. scans, CT scans
*Functional: • Pacemaker • Pacemaker • Pacemaker • Pacemaker and isotope
Items utilised (dual chamber) (dual chamber) (dual chamber) (dual chamber) studies. PET scans
towards treating or R56 167. R62 637. R62 637. R62 637. only included
supporting a bodily • Endovascular • Spinal including • Spinal including • Spinal including as indicated per
function option)
and catheter- artificial disc artificial disc artificial disc
based procedures R58 102. R58 212. R67 215. Oncology Oncology programme. 100% of Scheme Oncology programme. 100% of Scheme
– no benefit. • Drug-eluting • Drug-eluting • Drug-eluting tariff. DSP available. tariff. DSP available. Access to extended
• Spinal R32 892. stents R18 999. stents R18 999. stents R22 384. protocols.
• Artificial disk – • Mesh R18 999. • Mesh R18 999. • Mesh R19 712.
Mammary surgery No benefit for 100% Scheme tariff for reconstructive surgery (which may
no benefit. • Gynaecology/ • Gynaecology/ • Gynaecology/ (Breast cancer reconstructive include symmetrising, partial or total mastectomy etc.) on the
• Drug-eluting Urology Urology Urology patient) surgery (which unaffected (non-cancerous) breast of a breast cancer patient.
stents – PMBs R14 190. R14 249. R16 269. may include
and DSP products • Lens implants • Lens implants • Lens implants symmetrising, The benefit is limited to R36 750 and is subject to
partial or total pre-authorisation.
only R12 184 R12 184 R18 014
• Mesh R12 349. a lens per eye. a lens per eye. a lens per eye. mastectomy
• Gynaecology/ • Joint • Joint replacements: • Joint etc.) on the
Urology R8 906. replacements: - Hip replacement replacements: unaffected
(non-cancerous)
• Lens implants - Hip replacement and other major - Hip replacement
breast of a breast
R6 769 a lens and other major joints R52 248. and other major cancer patient.
per eye. joints R52 188. - Knee replacement joints R60 144.
- Knee replacement R60 857. - Knee replacement Peritoneal dialysis 100% Scheme tariff. Subject to pre-authorisation and DSPs.
R60 560. - Minor joints R69 644. and haemodialysis
- Minor joints R22 502. - Minor joints HIV/AIDS 100% Scheme tariff. Subject to pre-authorisation and DSPs.
R22 502. R22 384.
Confinements 100% Scheme tariff.
Prosthesis – Limited to Limited to Limited to Limited to (Birthing)
External R22 918 R27 311 R27 431 R30 993
per family. per family. per family. per family.
COMPARATIVE GUIDE 2021 13PACE1 PACE2 PACE3 PACE4 PACE1 PACE2 PACE3 PACE4
Refractive surgery 100% Scheme 100% Scheme 100% Scheme tariff. Diabetes primary 100% of Scheme tariff subject to registration with HaloCare.
and all types tariff. Limited to tariff. Limited to Limited to R10 094 per eye. care consultation 2 primary care consultations at Dis-Chem Pharmacies limited to R359 per
of procedures R8 977 per eye. R9 380 per eye. consultation. Paid first from the “FP and specialist consultations” day-to-day benefit,
to improve or thereafter Scheme risk.
stabilise vision
(except cataracts) Basic and specialised Savings first. Savings first. Savings first. Limited to
dentistry Basic: Basic: Basic: M = R12 454,
Midwife-assisted 100% Scheme tariff. Preventative Preventative Preventative M1+ = R21 021.
births benefit or savings benefit or savings benefit or savings (Subject to overall
account. Limit once account. Limit once account. Limit once day-to-day limit)
Supplementary 100% Scheme tariff.
services savings exceeded. savings exceeded. savings exceeded. Orthodontic:
Specialised: Specialised: Specialised: Subject to pre-
Alternatives to 100% Scheme tariff. Savings account Savings account Savings account authorisation.
hospitalisation then limit. then limit. then limit.
Orthodontic: Orthodontic: Orthodontic:
Palliative care 100% Scheme 100% Scheme tariff. Limited to R 15 000 for three (3) months. Subject to Subject to Subject to
and Home-based tariff. Limited to R Total benefit limited to R45 000. Subject to pre-authorisation pre-authorisation. pre-authorisation. pre-authorisation.
care in lieu of 10 000 for three and DSPs. Limited to Limited to Limited to
hospitalisation (3) months. Total M = R4 131, M = R6 926, M = R7 463,
benefit limited
M1+ = R8 384. M1+ = R13 852. M1+ = R13 912.
to R30 000.
(Subject to overall (Subject to overall (Subject to overall
Subject to pre-
authorisation and day-to-day limit) day-to-day limit) day-to-day limit)
DSPs. Medical aids, Savings first. Savings first. 100% Scheme tariff. Limited to R10 450 per
Emergency Services rendered by ER24. apparatus and 100% Scheme family. (Subject to overall day-to-day limit).
evacuation appliances tariff. Limited
to R11 519 per
Day procedures Day procedures at a day-hospital facility funded at 100% Scheme tariff. Subject to pre- family. (Subject to
at a day-hospital authorisation. DSPs apply for PMBs overall day-to-day
facility limit).
International travel Up to R10 million and a maximum of 90 days. Services rendered by Bryte Insurance and Wheel chairs Subject to medical Limit on wheelchairs of
cover managed by ER24. apparatus and R14 131 per family per 48 months.
appliance limits.
Out-of-hospital benefits Hearing aids are
subject to pre-
Limited to R8 000
per family every 24
Limit on hearing
aids of R28 796
Limit on hearing
aids of R32 418
Limit on hearing
aids of R36 098
authorisation months. (Subject per beneficiary per per beneficiary per per beneficiary per
Note: Benefits below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service to the overall day- 24 months. 24 months. 24 months.
providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP). to-day limit).
Members are required to obtain pre-authorisation for all planned treatments and/or procedures. Approved PMBs will
Insulin pump No benefit. 100% Scheme
be paid from scheme risk.
(excluding tariff. Limited
consumables) to R42 000
PACE1 PACE2 PACE3 PACE4 per beneficiary
every 24 months.
Overall day-to-day M = R10 901, M = R15 389, M = R19 237, M = R35 861, Subject to pre-
limit M1+ = R21 801. M1+ = R30 779. M1+ = R39 756. M1+ = R57 829. authorisation.
FP and specialist Savings first. Savings first.Limited to Limited to Supplementary Savings first. Savings first. Savings first. Limited to
consultations Limited to M = R4 394, M = R5 640, services Limited to Limited to Limited to M = R5 640,
M = R2 245, M1+ = R8 906. (Subject to overall M1+ = R9 144. M = R4 405, M = R5 523, M = R2 684, M1+ = R11 102.
M1+ = R4 512. day-to-day limit) (Subject to overall M1+ = R9 144. M1+ = R11 102. M1+ = R5 640. (Subject to overall
(Subject to overall day-to-day limit) (Subject to overall (Subject to overall (Subject to overall day-to-day limit)
day-to-day limit) day-to-day limit) day-to-day limit) day-to-day limit)
14 COMPARATIVE GUIDE 2021PACE1 PACE2 PACE3 PACE4 Medicine
Wound care benefit Savings first. Savings first. Savings first. Limited to
(incl. dressings, 100% Scheme 100% Scheme 100% Scheme R13 774 per Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers, designated
negative pressure tariff. Limited to tariff. Limited to tariff. Limited to family. (Subject to service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP). Refer to the Chronic
wound therapy R3 622 per family. R6 887 per family. R10 687 per overall day-to-day Conditions List at the back of the Comparative Guide.
-NPWT- treatment (Subject to overall (Subject to overall family. (Subject to limit)
Note: Approved CDL, PMB and non-CDL chronic medicine costs will be paid from the non-CDL chronic medicine limit
and related nursing day-to-day limit) day-to-day limit) overall day-to-day
services – limit) first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
out-of-hospital) Members will not incur co-payments for PMB medications that are on the formulary for which there is no generic
alternative.
Optometry benefit Benefits available every 24 months from date of service.
(PPN capitation Network Provider (PPN) Note: Approved PMB biological and Non-PMB biological medicine costs will be paid from the Biological limit first.
provider) Consultation - 1 per beneficiary. Once the limit is depleted, only PMB biological medicine costs will continue to be paid unlimited from Scheme risk.
Frame = R825 covered AND
100% of cost of standard lenses (single vision OR bifocal OR multifocal) PACE1 PACE2 PACE3 PACE4
OR
Non-network Provider CDL & PMB chronic 100% Scheme 100% Scheme 100% Scheme 100% Scheme
Consultation - R350 fee at non-network provider Frame = R598 AND medicine tariff. Co-payment tariff. Co-payment tariff. Co-payment tariff. Co-payment
Single vision lenses = R210 OR of 35% for of 30% for of 25% for of 20% for
Bifocal lenses = R445 OR non-formulary non-formulary non-formulary non-formulary
Multifocal lenses = R770 medicine. medicine. medicine. medicine.
Contact lenses In lieu of glasses members can opt for contact lenses Non-CDL chronic 7 conditions. 18 conditions. 19 conditions. 28 conditions.
Network Provider (PPN) Network Provider medicine 90% Scheme tariff. 90% Scheme tariff. 90% Scheme tariff. 90% Scheme tariff.
Contact lenses = R1 565 (PPN) Limited to Limited to Limited to Limited to
OR Contact lenses = M = R6 650, M = R9 144, M = R14 749, M = R19 889,
Non-network Provider R1 850 M1+ = R13 299. M1+ = R18 287. M1+ = R29 496. M1+ = R39 958.
Contact lenses = R1 565 OR Co-payment Co-payment Co-payment Co-payment
Non-network of 30% for of 25% for of 20% for of 15% for
Provider non-formulary non-formulary non-formulary non-formulary
Contact lenses = medicine. medicine. medicine. medicine.
R1 850 Biologicals and other PMBs only - Limited to Limited to Limited to
high-cost medicine subject to pre- R166 132 R332 485 R492 077
Basic radiology Savings first. 100% Scheme tariff. Savings first. 100% Scheme
approval. per beneficiary. per beneficiary. per beneficiary.
and pathology Limited to M = R3 265, M1+ = R6 531. 100% Scheme tariff. Limited to
(Subject to overall day-to-day limit) tariff. Limited to M = R5 640, Acute medicine Savings first. Savings first. Savings first. Limited to
M = R3 562, M1+ = R11 102. Limited to Limited to Limited to M = R8 906,
M1+ = R7 065. (Subject to overall M = R2 352, M = R4 869, M = R1 544, M1+ = R13 834.
(Subject to overall day-to-day limit) M1+ = R4 869. M1+ = R9 737. M1+ = R3 800. (10% co-payment)
day-to-day limit) (Subject to overall (Subject to overall (Subject to overall (Subject to overall
day-to-day limit). day-to-day limit). day-to-day limit). day-to-day limit).
Specialised 100% Scheme MRI/CT scans: Maximum of 3 scans per beneficiary.
diagnostic imaging tariff. Limited PET scan: 1 scan per beneficiary. 100% Scheme tariff. Over-the-counter *Member choice: 1. R683 OTC limit OR 2. Access to full savings Savings account.
(Including MRI scans, to R14 606 per (OTC) medicine for OTC purchases (after R683 limit) = self-payment gap
CT scans and isotope family. Includes sunscreen, accumulation. Subject to available savings.
studies. PET scans vitamins and minerals
only included as with nappi codes on
indicated per option) Scheme formulary
Rehabilitation Vested savings. 100% Scheme tariff. *The Default OTC choice is 1. R683 OTC limit. Members wishing to choose the other option are welcome to contact Bestmed
services after trauma
HIV/AIDS 100% Scheme tariff. Subject to pre-authorisation and DSPs.
Oncology Oncology programme. 100% of Scheme 100% of Scheme tariff. DSP available.
tariff. DSP available. Access to extended protocols.
Peritoneal dialysis 100% Scheme tariff. Subject to pre-authorisation and DSPs.
and haemodialysis
COMPARATIVE GUIDE 2021 15Preventative care benefits PACE1 PACE2 PACE3 PACE4
Intra-oral Two (2) photos per year for all ages.
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers,
radiograph
designated service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP).
Scaling and/or Twice per year for all ages.
PACE1 PACE2 PACE3 PACE4 polishing
Preventative care • Flu vaccines. • Flu vaccines. Fluoride Twice per year for all ages.
• Pneumonia • Pneumonia vaccines. treatment
Note: Refer to vaccines. • Travel vaccines.
Scheme rules for • Travel vaccines. • Paediatric immunisations. Up to and including 21 years. Frequency must be in accordance with accepted protocol.
Fissure sealing
funding criteria
• Paediatric • Female contraceptives – R2 315 per beneficiary per year.
applicable to each
immunisations. • Back and neck preventative programme. Space Once per space during the primary and mixed denture stage.
preventative
care benefit. • Female • Preventative dentistry. maintainers
contraceptives – • Haemophilus influenzae Type B vaccine. (HIB).
R2 315 per • Mammogram – ages 40 and above, once every 24 months. Maternity 100% Scheme tariff. Subject to the following benefits:
beneficiary per • PSA screening – ages 50 and above, every 24 months. Benefits
year. • HPV vaccinations. Consultations:
• Back and neck • Bone densitometry. • 9 antenatal consultations at a FP OR gynaecologist OR midwife.
preventative • Pap smear – ages 18 and above, every 24 months. • 1 post-natal consultation at a FP OR gynaecologist OR midwife.
programme. Ultrasounds:
• Preventative • 1 x 2D ultrasound scan at 1st trimester (between 10 to 12 weeks) at a FP OR
dentistry. gynaecologist OR radiologist.
• Haemophilus • 1 x 2D ultrasound scan at 2nd trimester (between 20 to 24 weeks) at a FP OR
influenzae Type B gynaecologist OR radiologist.
vaccine. (HIB). Supplements:
• Mammogram • Any item categorised as a maternity supplement can be claimed up to a maximum of R100
– ages 40 and per claim, once a month, for a maximum of 9 months.
above, once every
24 months. Disclaimer on exclusions: General and option-specific exclusions apply. Please refer to www.bestmed.co.za for more details.
• HPV vaccinations.
• Pap smear – age
18 and above,
every 24 months.
• PSA screening
– ages 50 and
above, every 24
months.
Preventative
dentistry:
General Once a year for members 12 years and above. Twice a year for members under 12 years.
full-mouth
examination by
a general dentist
(incl. gloves and
use of sterile
equipment)
Full-mouth intra- Once every 36 months for all ages.
oral radiographs
16 COMPARATIVE GUIDE 2021Contributions
PACE1 PACE2 PACE3 PACE4
Medical Savings Account 19% 14% 14% 3%
Principal Member Risk R3 307 R4 988 R5 726 R8 068
Savings R776 R812 R932 R250
Total R4 083 R5 800 R6 658 R8 318
Adult Dependant Risk R2 323 R4 891 R4 610 R8 068 PULSE
Savings R545 R796 R750 R250
Total R2 868 R5 687 R5 360 R8 318
Child Dependant Risk R835 R1 100 R985 R1 891
Savings R196 R179 R160 R58
Total R1 031 R1 279 R1 145 R1 949
Maximum contribution
4
child dependant*
Recognition of a Child dependants under the age of 21 years and registered students up to the age of
child dependant 26 years, in accordance with the Rules, are regarded as child dependants.
*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; TEMPO = Biometric Screenings; HIB = Haemophilus influenzae Type B vaccine; HPV = Human
Papilloma Virus; M = Member; M1+ = Member and family; MRI/CT scans = Magnetic Resonance Imaging/Computed
Tomography scans; MRP = Mediscor Reference Price; NP = Network Provider; PET scan = Positron Emission
Tomography scan; PMB = Prescribed Minimum Benefits; PPN = Preferred Provider Negotiators; PSA = Prostate
Specific Antigen.
Unlimited FP
consultations
on our Pulse
Network!
COMPARATIVE GUIDE 2021 17The Pulse range is ideally suitable for you if:
PULSE1 PULSE2
• You are seeking a plan option that is based on your income (Pulse1).
• You are comfortable with making use of designated service providers (DSPs) within our Pulse network. Major medical maxillofacial No benefit. 100% Scheme tariff.
• You are looking for unlimited comprehensive cover for hospitalisation and the added benefit of preventative care. surgery strictly related to certain
conditions
Dental and oral surgery No benefit. 100% Scheme tariff.
Method of Scheme benefit payment (In- or out of hospital)
Prosthesis (subject to preferred 100% Scheme tariff. 100% Scheme tariff.
PULSE1 PULSE2 provider, otherwise limits and Limited to R53 079 per family. Limited to R106 277 per family.
• In-hospital benefits are paid from Scheme risk. • In-hospital benefits are paid from Scheme risk. co-payments apply)
• Some preventative care benefits are available from • Some day-to-day benefits and preventative care Prosthesis – Internal Sub-limits per beneficiary: Sub-limits per beneficiary:
Scheme risk. benefits are available from Scheme risk. • *Functional R11 281. • *Functional R17 634.
• Some out-of-hospital benefits are paid from • Some out-of-hospital benefits are paid from Note: Sub-limit subject to overall • Vascular R26 302. • Vascular R41 086.
Scheme risk. Scheme risk. annual prosthesis limit • Pacemaker (dual chamber) • Pacemaker (dual chamber)
• Only Pulse specialist DSP network. • Only Pulse specialist DSP network. R42 986. R55 692.
*Functional: Items utilised
• Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs. • Endovascular and catheter-based • Spinal R41 086.
towards treating or supporting
a bodily function procedures – no benefit. • Artificial disk R18 049.
• Spinal R26 302. • Drug-eluting stents R18 049.
• Artificial disk – no benefit. • Mesh R18 049.
In-hospital benefits • Drug-eluting stents – PMBs and • Gynaecology/Urology R13 419.
DSP products only. • Lens implants R11 519 a lens
All benefits below are subject to pre-authorisation, clinical protocols, funding guidelines and designated hospital • Mesh R9 619. per eye.
networks. • Gynaecology/Urology R7 944. • Joint replacements:
Members are required to obtain pre-authorisation for all planned procedures at least 14 (fourteen) days before the • Lens implants R5 523 a lens per - Hip replacement and other major
event. However, in the case of an emergency, the member, their representative or the hospital must notify Bestmed eye. joints R49 160.
of the member’s hospitalisation as soon as possible or on the first working day after admission to hospital. - Knee replacement R57 413.
- Minor joints R21 374.
PULSE1 PULSE2 Prosthesis – External No benefit (PMBs only). Limited to R25 649 per family.
Accommodation (hospital stay) 100% Scheme tariff at a DSP hospital. Exclusions (Prosthesis sub-limit Joint replacement surgery (except Not applicable.
and theatre fees subject to preferred provider, for PMBs).
otherwise limits and PMBs subject to prosthesis
Take-home medicine 100% Scheme tariff. 100% Scheme tariff. co-payments apply) limits:
Medicine limited to 3 days. Medicine limited to 7 days. • Hip replacement and other major
Treatment in mental health 100% Scheme tariff. Limited to 21 days per beneficiary. joints R26 956.
clinics • Knee replacement R34 080.
• Minor joints R12 765.
Treatment of chemical and 100% Scheme tariff (only PMBs). 100% Scheme tariff. Limited to 21
substance abuse Limited to 21 days per beneficiary. days or R32 299 per beneficiary. Orthopaedic and medical 100% Scheme tariff. 100% Scheme tariff.
Subject to network facilities. Subject to network facilities. appliances Limited to R6 531 per family.
Consultations and procedures 100% Scheme tariff. Basic radiology and pathology 100% Scheme tariff.
Surgical procedures and 100% Scheme tariff. Excluded 100% Scheme tariff. Specialised diagnostic imaging 100% Scheme tariff. Subject to pre-authorisation.
anaesthetics from benefits: functional nasal
surgery, surgery for medical (Including MRI scans, CT scans
conditions e.g. Epilepsy, and isotope studies. PET scans
Parkinson’s disease and only included as indicated per
procedures where stimulators option)
are used.
Oncology Oncology programme. 100% of Scheme tariff. DSP available.
Organ transplants 100% Scheme tariff (only PMBs).
Peritoneal dialysis and 100% Scheme tariff. Subject to pre-authorisation and DSPs.
haemodialysis
18 COMPARATIVE GUIDE 2021PULSE1 PULSE2 Out-of-hospital benefits
Confinements (Birthing) 100% Scheme tariff.
Note: Granting of benefits under the primary care services and the Scheme benefits shall be subject to treatment
Mammary surgery No benefit for reconstructive 100% Scheme tariff for protocols, preferred providers, DSPs, dental procedure codes, pathology and radiology lists of codes and medicine
(Breast cancer patients) surgery (which may include reconstructive surgery (which formularies as accepted by the Scheme.
symmetrising, partial or total may include symmetrising, partial
mastectomy etc.) on the or total mastectomy etc.) on the Members are required to obtain pre-authorisation for all planned treatments and/or procedures.
unaffected (non-cancerous) unaffected (non-cancerous)
breast of a breast cancer patient. breast of a breast cancer patient. PULSE1 PULSE2
The benefit is limited to
R36 750 and is subject to pre- Overall day-to-day limit N/A M = R14 546, M1+ = R28 914.
authorisation.
FP consultations Unlimited FP visits. Subject to Unlimited FP visits at Bestmed FP
Refractive surgery and all types No benefit (PMBs only). 100% Scheme tariff. Limited to Bestmed Pulse1 FP network. network providers.
of procedures to improve or R9 440 per eye.
stabilise vision (except cataracts) Diabetes primary care 100% of Scheme tariff subject to registration with HaloCare.
consultation 2 primary care consultations at Dis-Chem Pharmacies limited to R359
Midwife-assisted births 100% Scheme tariff. per consultation.
Supplementary services 100% Scheme tariff.
Pulse2 option: Paid first from the day-to-day benefit, thereafter Scheme
HIV/AIDS 100% Scheme tariff. Subject to pre-authorisation and DSPs. risk.
Alternatives to hospitalisation 100% Scheme tariff. Casualty and out-of-network FP Limited to R1 425 per family per Limited to R1 544 per family per
Palliative care and Home-based 100% Scheme tariff. Limited to 100% Scheme tariff. Limited to visits year. year.
care in lieu of hospitalisation R8 000 per month for 3 months. R15 000 per month for 3 months.
Total benefit limited to R24 000. Total benefit limited to R45 000. Specialist consultations Specialist consultations must Specialist consultations must be
Subject to pre-authorisation and Subject to pre-authorisation and be referred by a Pulse1 Network referred by Network Provider.
DSPs. DSPs. Provider. Limited to M = R1 187, Limited to M = R3 207, M1+ = R6 175.
M1+ = R 1 782. Subject to overall day-to-day limit.
Emergency evacuation Services rendered by ER24 Subject to Pulse Specialist DSP Subject to Pulse specialist DSP
network. R500 penalty for non- network.
Day procedures at a day-hospital Day procedures at a day-hospital facility funded at 100% Scheme tariff. referral to specialists in PMB
facility Subject to pre-authorisation. DSPs apply for PMBs cases.
International travel cover Up to R10 million and a maximum of 90 days. Services rendered by Bryte Basic and specialised dentistry Basic dentistry: Subject to Basic and specialised dentistry
Insurance and managed by ER24. Bestmed Pulse Dental Network. is subject to pre-authorisation.
Specialised dentistry: No benefit. Limited to
Co-payments Co-payment where procedure has Co-payment of up to R11 874
M = R7 303,
been clinically approved: per event for voluntary use of a
M1+ = R9 262
• R3 800 on all laparoscopic non-DSP hospital.
Subject to overall day-to-day limit.
procedures,
• R3 800 on prostate procedures, Medical aids, apparatus and No benefit. 100% Scheme tariff. Limited to
• R3 800 on procedures for appliances R10 331 per family. Subject to
prolapse/incontinence, overall day-to-day limit.
• R3 800 on arthroscopy other Wheelchairs No benefit. Limit on wheelchairs of
than acute trauma, R13 299 per family per 48 months.
• R3 800 on endoscopy
Hearing aids are subject to No benefit. Limited to R28 736 per beneficiary
investigations done primarily in
pre-authorisation. per 24 months at DSP. Pre-approval
hospital
required, Subject to quotation,
• Co-payment of up to R11 874 motivation and audiogram.
per event for voluntary use of
a non-DSP hospital. Supplementary services No benefit. Limited to
M = R4 275,
M1+ = R8 490.
(Subject to overall day-to-day
limit)
COMPARATIVE GUIDE 2021 19PULSE1 PULSE2 Medicine
Wound care benefit (incl. No benefit. Limited to R9 975 per family.
dressings, negative pressure Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers, designated
wound therapy treatment service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP). Refer to the Chronic
-NPWT- and related nursing Conditions List at the back of the Comparative Guide.
services – out-of-hospital)
Note: Approved CDL, PMB and non-CDL chronic medicine costs will be paid from the non-CDL chronic medicine limit
Optometry benefit Benefits available every 24 Benefits available every 24 first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
(PPN capitation provider) months from date of service at months from date of service.
Members will not incur co-payments for PMB medications that are on the formulary for which there is no generic
PPN provider only. Network Provider (PPN)
Consultation - 1 per beneficiary. alternative.
Consultation - only PPN Frame = R825 covered AND Note: Approved PMB biological and Non-PMB biological medicine costs will be paid from the Biological limit first.
providers. 100% of cost of standard lenses Once the limit is depleted, only PMB biological medicine costs will continue to be paid unlimited from Scheme risk.
Frame = R225 covered AND (single vision OR bifocal OR
100% of cost of standard lenses multifocal) OR Contact lenses =
Single vision lenses = R210 OR R1 565 PULSE1 PULSE2
Bifocal lenses = R445 OR OR
CDL & PMB chronic medicine 100% Scheme tariff. 100% Scheme tariff.
Non-network Provider
40% co-payment on 25% co-payment on
Consultation - R350 fee at non-
In lieu of glasses members can opt non-formulary medicine. non-formulary medicine.
network provider Frame = R598
for contact lenses, limited to R630 AND Non-CDL chronic medicine No benefit. 16 conditions.
Single vision lenses = R210 OR 90% Scheme tariff.
Bifocal lenses = R445 OR Limited to M = R6 887,
Multifocal lenses = R770 M1+ = R13 774.
In lieu of glasses members can Co-payment of 20% for
opt for contact lenses, limited to non-formulary medicine.
R1 565
Biologicals and other high-cost PMBs only - subject to Limited to R156 743 per
Basic radiology and Pulse1 Protocols and tariff lists Subject to NP protocols and tariff medicine pre-approval. beneficiary.
pathology apply. Referral by Pulse1 NP lists. (Subject to overall day-to-
day limit). Referral by NP required. Acute medicine 100% Scheme tariff. 100% Scheme tariff.
Subject to pre-authorisation. Subject to Bestmed formulary. Limited to M = R4 572,
M1+ = R9 262. (Subject to overall
Specialised diagnostic imaging No benefit. Subject to pre-authorisation. day-to-day limit)
(Including MRI scans, CT scans MRI/CT scans: A maximum of
and isotope studies. PET scans 3 scans per beneficiary. Over-the-counter (OTC) medicine Limited to R387 per family. Limited to R608 per family.
only included as indicated per PET scans: 1 scan per beneficiary.
option) Includes sunscreen, vitamins and
minerals with nappi codes on
HIV/AIDS 100% Scheme tariff. Subject to pre-authorisation and DSPs. Scheme formulary
Peritoneal dialysis and 100% Scheme tariff. Subject to pre-authorisation and DSPs.
haemodialysis
Oncology Oncology programme. 100% of Scheme tariff. DSP available.
Rehabilitation services after No benefit.
trauma
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