705564 Bestmed Generic Untabbed Comparative …...2 Bestmed Comparative Guide 2016 Why choose...

Better living. Better life.

Comparative Guide 2016

2 Bestmed Comparative Guide 2016

Why choose Bestmed?

Over the years Bestmed has grown sustainably and has been able to build a reputable name in the industry. Our focus is to provide superior healthcare to our members. We are, after all, a medical scheme for members, by members. That is why it is gratifying to know that we have been honoured with the Healthcare Product Supplier of the Year award from the Financial Intermediaries Association of South Africa.

Bestmed is still raising the bar in the medical aid industry to the point where we have grown our membership to reach the fifth overall position countrywide. Going forward, Bestmed is also focused on serving our members with the legendary Bestmed touch.

As a self-administered scheme, Bestmed now has more than 93 000 principal members and provides healthcare benefits to almost 200 000 lives. With our extensive experience and exceptional expertise, we can negotiate with our service providers to offer our members benefits and services that are, Rand-for-Rand, the best value compared to other large open medical schemes.

The right fit

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

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

Focused on wellness

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

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

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

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

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

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

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

The corporate partnership

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

About Bestmed

3Bestmed Comparative Guide 2016

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

Don’t worry, be appy!

Bestmed is proud to inform members that the Bestmed app that was launched at the start of 2015, is now app-reciably better. Members are now able to get even more access to greater functionalities by simply downloading the Bestmed app onto their smartphones.

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

The second phase of the development of the Bestmed app has been finalised and the app now boasts with a host of new functionalities that include great features like a service provider search function, updating of your personal details and receiving your tax certificate directly to your cell phone.

Bestmed Provider Network

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

Member advantages of using Bestmed Provider Networks

• Provider fees are set and managed as agreed.

• Quality of healthcare services are enhanced.

• Downstream costs are better managed.

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

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

• A longer lasting medical savings account.

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

• A dedicated provider consultant service is available to the Network Providers.

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

You need to register on the Bestmed website at www.bestmed.co.za and create your personal username and password, if you have not done so already. This will allow you, as the member, to access the different updated provider network lists and utilise all the added benefits of the website.


Below is a summary of the current Bestmed Provider networks:

Healthcare Provider Networks

Family practitioners

Specialists

Pathology

Oncology

Pharmacies

Dentists

Dental therapists

Dental technicians

Orthodontists

Ancillary Networks

Audiologists and speech therapists

Physiotherapists

Occupational therapists

Hearing aid acousticians

Counsellors

Midwives

Psychologists

Biokineticists

Dieticians

Product Supply Networks

Stents and pacemakers

Orthopaedic prosthesis

Oxygen supply

Sleep apnoea devices

Hearing aid devices

Service Networks

Drug and alcohol rehabilitation

Emergency services

Optometry services

Renal dialysis

Wound therapy

The Healthcare Networks and Ancillary Networks are applicable to Beat1 to Beat4 and Pace1 to Pace4 only. Product Supply

Networks and Service Supply Networks are applicable to Beat1 to Beat4, Pace1 to Pace4 and Pulse1 and Pulse2.

Did you know that you can make your benefits last longer?

Simply ask your doctor to prescribe generic medicines where possible.

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


Bestmed Managed Care Programmes

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

Oncology Care

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

Bestmed provides oncology benefits applying evidence-based medicine principles and considering affordability across the different benefit options. It has therefore appointed the Independent Clinical Oncology Network (ICON) for all the benefit options as Designated Service Provider (DSP), excluding members on Pulse1, Pace3 and Pace4. Bestmed uses the Standard option of ICON for all members. Members on Pace3 and Pace4 use the South African Oncology Consortium (SAOC) cancer treatment guidelines. Pulse1 members are referred to state facilities for treatment, as these are the designated service providers for this option.

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

HIV/AIDS Care

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

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

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

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

The programme also makes provision for blood tests to follow the course of the disease and to measure the response to treatment, medicine and anti–retrovirals, as well as medicine specifically used to fight the virus. The treatment programme covered by the Scheme is based on the HIV/AIDS funding guideline and approved treatment depends on the clinical parameters of each individual. The stage of the disease and the results of blood tests determine what treatment will be covered and how the individual must be followed up. Cover is also provided for mother–to–child transmission in pregnancy and as post–exposure prophylaxis. Details can be obtained by contacting OneHealth Managed Care at the telephone numbers listed under contact details. Optipharm is the Designated Service Provider for dispensing anti-retroviral medication to Bestmed members.

Pulse1 and 2 members are advised to send their pathology claims for HIV/AIDS to Bestmed in order to get all the tariffs paid. The e-mail address is [email protected].


Dialysis Care

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

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

Alcohol and Substance Abuse Care

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

Wound Care

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

Stoma Care

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

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

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

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

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

• Free deliveries will be done free of charge.

Preventative Care

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

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

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

Flu vaccines: All members are eligible, and annually receive a letter to remind them of this preventative care benefit when flu vaccines become available.

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


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

Back and neck preoperational assessment: Documented Based Care (DBC) for back and neck rehabilitation is the Bestmed back and neck programme which is an active spine and joint rehabilitation and treatment programme that has been developed in Finland over the past 20 years.

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

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

All members, except those on Pulse1, are eligible for this benefit. For a member to register on the programme he/she needs to visit a DBC clinic and have an assessment done by the doctor who will then motivate if the patient qualifies for this rehabilitation programme. The member can thereafter send the application to Bestmed for authorisation. It includes twelve sessions during a six-week period and an evaluation by a Documented Based Care (DBC) clinic.

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

Human papillomavirus vaccine (HPV): The HPV vaccination is administered to assist in the prevention of cervical cancer and anal cancer. This benefit is available to all females between nine and twenty-six years of age.

Female contraceptives: All females of child-bearing age qualify for female contraceptives to the value of R1 550 per family per year.

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

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

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

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

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

Health Check: This programme is available to all Bestmed members, once a year, for free biometric screenings.

These screenings consist of a detailed questionnaire that you may obtain from the Bestmed website. Print the questionnaire and complete it. Upon completion please take it to a Dis-Chem, Clicks, MediRite, ScriptSavers, or Van Heerden pharmacy to have your Health Check completed. The following information will be obtained from you: your height and weight, while your blood pressure and rapid cholesterol as well as glucose levels will be tested. Once finalised, please send it back to Bestmed. Your results will be loaded onto the system and you will receive a personal report about your health status.

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


Maternity Care

With so many things to juggle, the Maternity Care programme is created to help moms and dads through the entire pregnancy and the first two years with a new little one in the home – without missing a beat. At Bestmed we want you to enjoy this entire experience.

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

• A 24-hour professional medical advice line.

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

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

• To make sure your pregnancy starts right you will receive a welcome pack containing an informative pregnancy book to guide you through the stages and discount vouchers for various baby items. Mom can also expect a pregnancy health pack, via Fastmail, within the first month of registration.

• In your second month after registration, we will send you a beautiful baby bag, to your door, packed with products to use after baby’s birth. Moms-to-be can expect their bag to contain wonderful products.

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

Midwife-assisted

births are covered

at 100% of

Scheme tariff on

all options.

No folly in folic acid. Folic acid should be taken regularly by all pregnant moms and people with a low immunity to disease. Folic acid prevents spina bifida in unborn babies and can play a role in cancer prevention. It is found in green leafy vegetables, liver, fruit and bran.

Beat

Beat

The Beat range offers flexible hospital benefits on all Beat options with limited savings to pay for out-of-hospital expenses on some options such as Beat2 and Beat3 but extensive out-of-hospital cover on Beat4. Beat1, 2 and 3 offer an

efficiency discount option called Beat1 Network, Beat2 Network and Beat3 Network.


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

available from Scheme risk benefit.

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

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

care services are available from Scheme risk benefit.

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

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

Some preventative care services are available from Scheme risk benefit.

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

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

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

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

savings. Some preventative care services are available from Scheme

risk benefit.

Method of Scheme benefit payment

Beat1 Beat2 Beat3 Beat4Accommodation (hospital stay) and theatre fees

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

100% Scheme tariff.

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

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

Treatment of chemical and substance abuse

100% Scheme tariff. Limited to 21 days or R24 000 per beneficiary. Subject to network facilities.

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

100% Scheme tariff.

Surgical procedures and anaesthetics 100% Scheme tariff.

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

Major medical maxillo-facial surgery strictly related to certain conditions

100% Scheme tariff. Limited to R9 600

per family.

100% Scheme tariff. Limited to R9 700 per family.


per family.

Dental and oral surgery Limited to R5 000 per family. Limited to R6 000 per family.

Limited to R7 500 per family.

In-hospital benefits

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

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

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

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

The Beat range offers flexible hospital benefits with limited savings to pay for out-of-hospital expenses on some options.

Cut out herbs before operations. Some herbal supplements - from the popular St John’s wort and ginkgo biloba to garlic, ginger, ginseng and feverfew - can cause increased bleeding during surgery, warn surgeons. It may be wise to stop taking herbal supplements, at least two weeks before surgery, and inform your surgeon about your herbal use.

Bea

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In-hospital benefits

Beat Network Range

In-hospital benefits (continued)

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


per family.

100% Scheme tariff. Limited to R59 250 per family. 100% Scheme tariff. Limited to R72 300

per family.

Prosthesis – Internal

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

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

Sub-limits per beneficiary:■■ Functional limited to

R10 000■■ Vascular R22 250■■ Pacemaker (dual

chamber) R30 500■■ Endovascular -

no benefit■■ Spinal R22 250■■ Artificial disk -

no benefit■■ Drug-eluting stents -

no benefit■■ Mesh R7 850■■ Gynaecology/Urology

R6 400■■ Lens implants R4 950

per lens

Sub-limits per beneficiary:■■ Functional limited to Functional limited to

R10 000 R11 000 ■■ Vascular R22 450■■ Pacemaker (dual chamber) R30 500■■ Endovascular - no benefit■■ Spinal R22 450■■ Artificial disk - no benefit■■ Drug-eluting stents - no benefit■■ Mesh R7 850■■ Gynaecology/Urology R6 500■■ Lens implants R5 050 per lens



chamber) R39 900■■ Endovascular –

no benefit■■ Spinal R23 800■■ Artificial disk -

no benefit■■ Drug-eluting stents

R13 400■■ Mesh R8 800■■ Gynaecology/Urology


per lens■■ Joint replacements:

■− Hip replacement and other major joints R24 500

■− Knee replacement R32 550

■− Minor joints R10 000

Prosthesis – External Limited to R14 200 per family.

Limited to R14 300 per family. Limited to R17 400 per family.

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

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

other major joints R23 500

■■ Knee replacement R28 950

■■ Minor joints R9 900

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

R23 690 R23 700■■ Knee replacement R29 250■■ Minor joints R10 000

Not applicable.

Orthopaedic and medical appliances 100% Scheme tariff.

Pathology 100% Scheme tariff.

Diagnostic imaging 100% Scheme tariff.

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

Oncology Oncology programme. 100% Scheme tariff.

Peritoneal dialysis and haemodialysis

100% Scheme tariff.

Confinements 100% Scheme tariff.

Refractive surgery 100% Scheme tariff. Subject to pre-authorisation and protocols. Limited to R6 500 per eye.

100% Scheme tariff. Subject to pre-authorisation

and protocols. Limited to R7 000 per eye.

Midwife-assisted births 100% Scheme tariff.

Supplementary services 100% Scheme tariff.

Alternatives to hospitalisation 100% Scheme tariff.

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

Co-payments Co-payment of R2 400 on all endoscopic investigations and specialised diagnostic imaging if done in private

hospital. Any other facility, no co-payment.

Co-payment of R2 400 on all endoscopic investigations if done in

private hospital. Any other facility, no co-payment.

Not applicable.

Beat


Out-of-hospital benefits

Beat1 Beat2 Beat3 Beat4Overall day-to-day limit Not applicable. M = R9 900, M1+ = R19 850.

GP and specialist consultations No benefit. Savings account. Savings first. Scheme tariffs apply. Limited to M = R2 450,

M1+ = R4 350. (Subject to overall day-to-day limit)

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

Orthodontic: Subject to pre-authorisation.

Savings first. Scheme tariffs apply. Limited to M = R4 100,

M1+ = R8 250. (Subject to overall day-to-day limit) Orthodontics are

subject to pre-authorisation.

Medical aids, apparatus and appliances including wheelchairs and hearing aids

No benefit. Savings account. Savings first. 100% Scheme tariff. Limited to R8 500 per

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

Supplementary services No benefit. Savings account. Savings first. Scheme tariffs apply. Limited to M = R3 700,


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

Savings first. 100% Scheme tariff. Limited to R2 600 per family. (Subject to overall day-to-day limit)

Savings first. 100% Scheme tariff. Limited to R3 700 per


Optometry benefit (PPN capitation provider)

No benefit. Savings account. ■■ Consultation R325■■ Frame R550

■− Single-vision lenses R150 OR

■− Bifocal lenses R325 OR

■− Multifocal lenses R600 ■■ Contact lenses R1 000

■■ Consultation R325■■ Frame R500

■− Single-vision lenses R150 OR

■− Bifocal lenses R325 OR

■− Multifocal lenses R600 ■■ Contact lenses R1 210

Diagnostic imaging and pathology

No benefit. Savings account. Savings first. Scheme tariffs apply. Limited to M = R2 470,


Specialised diagnostic imaging 100% Scheme tariff.Limited to R4 000 per family.

100% Scheme tariff. Limited to R8 350 per

family.

100% Scheme tariff.Limited to R12 550 per family.


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

Rehabilitation services after trauma

No benefit. Savings account. Vested savings.

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

Bea

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Beat1 Beat2 Beat3 Beat4CDL chronic medicine 100% Scheme tariff. Co-payment of 35% for non-formulary medicine. 100% Scheme tariff.

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

Non-CDL chronic medicine No benefit. 5 conditions.

85% Scheme tariff. Limited to M = R2 700, M1+ = R5 450.


16 conditions.



Biologicals and other high-cost medicine

No benefit.

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

(Subject to overall day-to-day limit)

Over-the-counter (OTC) medicine No benefit. Savings account. Paid from savings. Limited to R500.

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

Beat1 Beat2 Beat3 Beat4Preventative careHealth Check and lifestyle screenings

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

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

R1 550 per family■■ DBC programme■■ Health Check

(Biometric screenings)■■ Pap smear – ages 18 and

above, every 24 months.


R1 550 per family■■ DBC programme■■ Preventative dentistry

(incl. gloves and sterile equipment)

■■ Health Check (Biometric screenings)

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





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




■■ Haemophilus influenzae Type B vaccine (HIB)

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

50 years and above, every 24 months.


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

■■ One dietician counselling session per family.

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

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

Beat


Beat1 Beat2 Beat3 Beat4Reimbursement for CDL 100% Scheme tariff

Reimbursement for non-CDL No benefit 85% Scheme tariff

Non-formulary co-payment 35% 30%

No. of non-CDL conditions covered 0 5 16

CDL 1 Addison's disease

CDL 2 Asthma

CDL 3 Bipolar mood disorder

CDL 4 Bronchiectasis

CDL 5 Cardiomyopathy

CDL 6 Chronic renal failure

CDL 7 Chronic obstructive pulmonary disease (COPD)

CDL 8 Congestive heart failure

CDL 9 Coronary artery disease

CDL 10 Crohn's disease

CDL 11 Diabetes insipidus

CDL 12 Diabetes mellitus Type 1


CDL 14 Dysrhythmia

CDL 15 Epilepsy

CDL 16 Glaucoma

CDL 17 Haemophilia

CDL 18 HIV/AIDS

CDL 19 Hyperlipidaemia

CDL 20 Hypertension

CDL 21 Hypothyroidism

CDL 22 Multiple sclerosis

CDL 23 Parkinson's disease

CDL 24 Rheumatoid arthritis

CDL 25 Schizophrenia

CDL 26 Systemic lupus erythematosus (SLE)

CDL 27 Ulcerative colitis

non-CDL 1 Acne - severe

non-CDL 2Attention deficit disorder/Attention deficit hyperactivity

disorder (ADD/ADHD)

non-CDL 3 Allergic rhinitis

non-CDL 4 Eczema

non-CDL 5 Migraine prophylaxis

non-CDL 6 Gout prophylaxis

non-CDL 7 Endometriosis

non-CDL 8 Major depression

non-CDL 9 Chronic anaemia

non-CDL 10 Polycystic ovarian disease

non-CDL 11 Graves’ disease

non-CDL 12 Obsessive compulsive disorder

non-CDL 13 Stroke

non-CDL 14Paraplegia/Quadriplegia

(medication to treat)

non-CDL 15 Pulmonary embolism

non-CDL 16 Female menopause

The Chronic Disease List (CDL) provides cover for the 27 listed chronic conditions for which medical schemes must cover the diagnosis, medical management and medicines as published by the Council for Medical Schemes. Non-CDL chronic conditions are those additional conditions that Bestmed provides chronic medicine cover for. Authorisation for CDL and non-CDL chronic medicines is subject to clinical funding guidelines and protocols, formularies and Designated Service Providers (DSPs) where applicable. Below is the list of CDL and non-CDL conditions that Bestmed covers on the various benefit options. Note: Benefits mentioned below are subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP).

Chronic conditions list (CDL & non-CDL)B

eat


ContributionsBeat1 Beat2 Beat3 Beat4

Non-Network (NN)/ Network (N)

NN N NN N NN N NN

PRINCIPAL MEMBER

Risk R1 144 R1 029 R1 174 R1 057 R1 782 R1 604 R2 688

Savings R0 R0 R240 R216 R365 R328 R551

Total R1 144 R1 029 R1 414 R1 273 R2 147 R1 932 R3 239

ADULT DEPENDANT

Risk R888 R800 R912 R821 R1 266 R1 140 R2 220

Savings R0 R0 R187 R168 R259 R233 R455

Total R888 R800 R1 099 R989 R1 525 R1 373 R2 675

CHILD DEPENDANT

Risk R481 R433 R495 R445 R688 R619 R665

Savings R0 R0 R101 R91 R141 R127 R136

Total R481 R433 R596 R536 R829 R746 R801

Maximum contribution child dependants*

4

Recognition of a child dependant

Under 21, unless a registered student.

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

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

For a more detailed overview of your benefit option and to receive a membership guide please contact [email protected] Disclaimer: All the 2016 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 2016 benefit options and accompanying services including information in respect of the terms and conditions or any other matters is subject to prior approval of the Council for Medical Schemes (CMS) and may change without notice having due regard to the CMS’s further advices. Bestmed accepts no liability whatsoever for any loss whether direct, indirect or consequential arising from information provided in this brochure or any actions and/or transactions resulting therefrom. Please visit www.bestmed.co.za for the complete liability and responsibility disclaimer for Bestmed Medical Scheme as well as our terms and conditions.

Beat

App-iness. New and improved.

© Bestmed Medical Scheme 2016 Bestmed Medical Scheme is a registered Medical Scheme (reg. no. 1252) and an Authorised Financial Services Provider (FSP no. 44058).

Better living. Better life.

At the beginning of 2015, Bestmed launched its new App. Today, we’ve just made it app-reciably better! So, if you haven’t already downloaded the Bestmed App onto your smartphone, there’s no better time to do it than right now.

• Even more user-friendly home screen, with more functionalities, including a slide-out menu for ease of reference. • Receive your tax certificate straight to your smartphone. • Automatic updates on all communication the Scheme sends to its Members. • Quick information about your benefits, including hospital, chronic and savings balance sent straight to your phone. • Submit your chronic medication application form directly via the Bestmed App. • Update your personal details directly from your phone. • Search for a service provider in your chosen area of preference.

Here are seven reasons why:

For iPhone download the Bestmed App from the App Store For Android get the App from the Play Store or Windows Store

www.bestmed.co.za

So don’t delay, download your new and improved Bestmed App today.

Pace

The Pace range offers more comprehensive hospital benefits, Scheme benefits and additional savings benefits to cover extensive out-of-hospital expenses. The options in this category are Pace1, Pace2, Pace3 and Pace4.

Pace


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

services are available from Scheme risk benefit.

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

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


Pace1 Pace2 Pace3 Pace4Accommodation (hospital stay) and theatre fees

100% Scheme tariff.

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

Treatment in mental health clinics

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

Treatment of chemical and substance abuse

100% Scheme tariff.Limited to 21 days or R24 000 per beneficiary. Subject to network facilities.

Consultations and procedures 100% Scheme tariff.

Surgical procedures and anaesthetics

100% Scheme tariff.

Organ transplants 100% Scheme tariff. (Only PMBs)



per family.

100% Scheme tariff.

Dental and oral surgery Limited to R6 000 per family.




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


per family.


per family.


per family.


per family.


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



R11 500■■ Vascular R23 300 ■■ Pacemaker (dual

chamber) R39 850■■ Endovascular - no benefit■■ Spinal R23 300 ■■ Artificial disk - no benefit■■ Drug-eluting stents -

no benefit■■ Mesh R8 750 ■■ Gynaecology/Urology

R6 300 ■■ Lens implants R4 850

per lens



chamber) R44 400■■ Spinal R30 800■■ Artificial disk R13 500■■ Drug-eluting stents









chamber) R44 400■■ Spinal R30 900■■ Artificial disk R13 500■■ Drug-eluting stents








R14 000■■ Vascular R35 350■■ Pacemaker (dual chamber)

R44 400■■ Spinal R35 350■■ Artificial disk R15 850■■ Drug-eluting stents







In-hospital benefitsAll benefits below are subject to pre-authorisation and clinical protocols. All payments are made at Scheme tariff.

Pace



Pace1 Pace2 Pace3 Pace4

Prosthesis – External Limited to R17 100 per family.





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

other major joints R23 800■■ Knee replacement R31 600 ■■ Minor joints R9 800

Not applicable.

Orthopaedic and medical appliances

100% Scheme tariff.



Specialised diagnostic imaging 100% Scheme tariff.


Peritoneal dialysis and haemodialysis

100% Scheme tariff.


Refractive surgery 100% Scheme tariff. Limited to R7 000 per eye. 100% Scheme tariff. Limited to R7 500 per eye.

Midwife-assisted births 100% Scheme tariff.




Co-payments Not applicable.

Smile Smile Smile: There are approximately 642 skeletal muscles. It takes something like 43 muscles to frown but only 17 muscles to smile. You choose!

Don’t skip breakfast. Studies show that eating a proper breakfast is one of the most positive things you can do if you are trying to lose weight. Breakfast skippers tend to gain weight. A balanced breakfast includes fresh fruit or fruit juice, a high-fibre breakfast cereal, low-fat milk or yoghurt, wholewheat toast and a boiled egg.

Pace


Pace1 Pace2 Pace3 Pace4Overall day-to-day limit M = R8 450,

M1+ = R16 790.M = R11 740,

M1+ = R24 100. M = R15 000,

M1+ = R31 000.M = R28 000,

M1+ = R45 100.

GP and specialist consultations

Savings first. Limited to M = R1 650,


Savings first.Limited to M = R3 300,


Savings first. 100% Scheme tariff.

M = R2 700, M1+ = R7 950. (Subject to overall day-to-

day limit)

Limited to M = R4 200, M1+ = R6 800. (Subject to

overall day-to-day limit)

Basic and specialised dentistry

Savings first. Basic: Preventative benefit or

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

then limit.Orthodontic: Subject to

pre-authorisation.Limited to M = R3 000,




then limit.Orthodontic: Subject to

pre-authorisation.Limited to M = R5 050,




then limit. Orthodontic: Subject to

pre-authorisation. 100% Scheme tariff. Limited

to M = R5 450, M1+ = R9 350. (Subject to overall day-to-

day limit)

Limited to M = R9 050,M1+ = R15 350. (Subject to






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

Limit on wheelchairs of R10 500 per family per

48 months.

Limit on hearing aids of R21 400 per beneficiary per 24

months.


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


48 months.

Limit on hearing aids of R24 100 per beneficiary per 24

months.

100% Scheme tariff. Limited to R7 750 per family. (Subject

to overall day-to-day limit).


48 months.

Limit on hearing aids of R26 800 per beneficiary per

24 months.

Supplementary services Savings first.Limited to M = R3 300,


Savings first.Limited to M = R4 100,




Limited to M = R4 200,M1+ = R8 250. (Subject to









Limited to R10 300 per family. (Subject to overall

day-to-day limit)

Optometry benefit (PPN capitation provider)

■■ Consultation R325■■ Frame R550 AND

■− Single vision lenses R150 OR

■− Bifocal lenses R325 OR■− Multifocal lenses R600

■■ Contact lenses R1 000







■− Bifocal lenses R325 OR ■− Multifocal lenses R600


■■ Consultation R325■■ Frame R1 050 AND





Savings first. 100% Scheme tariff. Limited to M = R2 450,







(Subject to overall day-today limit)

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

Specialised diagnostic imaging


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

Rehabilitation services after trauma

Vested savings. 100% Scheme tariff.


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

Pace


Pace1 Pace2 Pace3 Pace4CDL chronic medicine 100% Scheme tariff.


100% Scheme tariff.Co-payment of 30% for non-formulary medicine.



Non-CDL chronic medicine

10 conditions. 85% Scheme tariff.

Limited to M = R6 500, M1+ = R13 080.



Limited to M = R8 950, M1+ = R17 900.



Limited to M = R14 400, M1+ = R28 750.



Limited to M = R19 450, M1+ = R38 950.



No benefit. Limited to R123 500 per beneficiary.

Limited to R247 000 per beneficiary.

Limited to R365 450 per beneficiary.

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




Savings first. Limited to M = R990,


Limited to M = R6 600, M1+ = R10 300. Subject

to MRP (10% co-payment)(Subject to day- to-day

overall limit)

Over-the-counter (OTC) medicine

Paid from savings. Limited to R500. Savings account.

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

Preventative care benefits

Pace1 Pace2 Pace3 Pace4Preventative care Health Check and lifestyle screenings


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




■■ Mammogram■■ HPV vaccines■■ Health Check

(Biometric screenings)■■ Pap smear – age 18 and

above, every 24 months.

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




■■ Mammogram■■ PSA screening – ages

50 and above, every 24 months

■■ HPV vaccines■■ Health Check

(Biometric screenings)■■ Pap smear – age 18 and

above, every 24 months■■ One dietician counselling

session per family.

■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations■■ Female contraceptives – R1 550 per family■■ DBC programme■■ Preventative dentistry (incl. gloves and sterile equipment)■■ Haemophilus influenzae Type B vaccine (HIB)■■ Mammogram■■ PSA screening - ages 50 and above, every 24 months■■ HPV vaccines■■ Bone densitometry■■ Health Check (Biometric screenings)■■ Pap smear – ages 18 and above, every 24 months■■ One dietician counselling session per family.

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

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

Pace


The Chronic Disease List (CDL) provides cover for the 27 listed chronic conditions for which medical schemes must cover the diagnosis, medical management and medicines as published by the Council for Medical Schemes. Non-CDL chronic conditions are those additional conditions that Bestmed provides chronic medicine cover for. Authorisation for CDL and non-CDL chronic medicines is subject to clinical funding guidelines and protocols, formularies and Designated Service Providers (DSPs) where applicable. Below is the list of CDL and non-CDL conditions that Bestmed covers on the various benefit options. Note: Benefits mentioned below are subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP).

Chronic conditions list (CDL)

Pace1 Pace2 Pace3 Pace4Reimbursement for CDL 100% Scheme tariff

Reimbursement for non-CDL 85% Scheme tariff

Non-formulary co-payment 35% 30% 25% 20%

No. of non-CDL conditions covered 10 31 45


CDL 2 Asthma












CDL 14 Dysrhythmia

CDL 15 Epilepsy

CDL 16 Glaucoma

CDL 17 Haemophilia

CDL 18 HIV/AIDS


CDL 20 Hypertension








You can save money by obtaining pre-authorisation for planned, in-hospital medical procedures in advance.

Cool off without a beer. Don’t eat carbohydrates for at least an hour after exercise. This will force your body to break down body fat, rather than using the food you ingest. Stick to fruit and fluids during that hour, but avoid beer.

Pace


Chronic conditions list (non-CDL)

Pace1 Pace2 Pace3 Pace4non-CDL 1 Acne - severe

non-CDL 2 Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD)


non-CDL 4 Eczema






non-CDL 10 Polycystic ovarian disease

non-CDL 11 Graves’ disease

non-CDL 12 Obsessive compulsive disorder

non-CDL 13 Stroke

non-CDL 14 Paraplegia/Quadriplegia (medication to treat)



non-CDL 17 Benign prostatic hypertrophy

non-CDL 18 Osteoporosis

non-CDL 19 Psoriasis

non-CDL 20 Urinary incontinence

non-CDL 21 Paget’s disease

non-CDL 22 Gastro oesophageal reflux disease (GORD)

non-CDL 23 Ankylosing spondylitis

non-CDL 24 Hypophyseal adenoma

non-CDL 25 Osteoarthritis

non-CDL 26 Alzheimer’s disease

non-CDL 27 Aplastic anaemia

non-CDL 28 Collagen diseases

non-CDL 29 Cushing’s syndrome

non-CDL 30 Cystic fibrosis

non-CDL 31 Dermatomyositis

non-CDL 32 Fibrosing alveolitis

non-CDL 33 Hyperthyroidism

non-CDL 34 Hypopituitarism

non-CDL 35 Idiopathic thrombocytopenic pupura

non-CDL 36 Motor neuron disease

non-CDL 37Muscular dystrophy and

inherited myopathies

non-CDL 38 Neuropathy

non-CDL 39 Myasthenia gravis

non-CDL 40 Polyarteritis nodosa

non-CDL 41 Pulmonary interstitial fibrosis

non-CDL 42 Scleroderma

non-CDL 43 Sjögren’s disease

non-CDL 44 Trigeminal neuralgia

non-CDL 45 Psoriatic arthritis

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

Pace


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

Pace1 Pace2 Pace3 Pace4Income level N/A ■< R98 500 p.a. > R98 501 p.a. N/A

PRINCIPAL MEMBER

Risk R2 209 R3 281 R3 239 R3 890 R5 263

Savings R552 R579 R571 R687 R163

Total R2 761 R3 860 R3 810 R4 577 R5 426

ADULT DEPENDANT

Risk R1 550 R3 216 R2 591 R3 103 R5 263

Savings R388 R568 R457 R548 R163

Total R1 938 R3 784 R3 048 R3 651 R5 426

CHILD DEPENDANT

Risk R558 R723 R601 R651 R1 233

Savings R139 R128 R106 R115 R38

Total R697 R851 R707 R766 R1 271

Maximum contribution child dependant*

4


Under 21, unless a registered student.

Contributions

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

Brush up on hygiene. Many people don’t know how to brush their teeth properly. Improper brushing can cause as much damage to the teeth and gums as not brushing at all. Lots of people don’t brush for long enough, don’t floss and don’t see a dentist regularly. Hold your toothbrush in the same way that you would hold a pencil, and brush for at least two minutes. This includes brushing the teeth, the junction of the teeth and gums, the tongue and the roof of the mouth. And you don’t need a fancy, angled toothbrush – just a sturdy, soft-bristled one that you replace each month.

Curry favour. Hot, spicy foods containing chillies or cayenne pepper trigger endorphins, the feel-good hormones. Endorphins have a powerful, almost narcotic, effect and make you feel good after exercising. But go easy on the lamb, pork and mutton and the high-fat, creamy dishes served in many Indian restaurants.


Pace

Pulse

Pulse

The Pulse range offers full hospital benefits and out-of-hospital benefits which are both provided by designated network providers only. The options in this category are Pulse1 and Pulse2.


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

network provider, CareCross, covers most out-of-hospital services. Some preventative care services are available from Scheme risk benefit.

In-hospital services are paid from Scheme risk benefit. The designated network provider, OneCare, covers most out-of-hospital services.

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


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

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


Treatment of chemical and substance abuse 100% Scheme tariff. (Only PMBs). 100% Scheme tariff.Limited to 21 days or R24 000 per beneficiary.

Subject to network facilities.


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

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

stimulators are used.

100% Scheme tariff.



No benefit. 100% Scheme tariff.

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





Note: Sub-limit subject to the above prosthesis limit


Sub-limits per beneficiary:■■ Functional R8 000■■ Vascular R18 650■■ Pacemaker (dual chamber) R30 500■■ Endovascular - no benefit■■ Spinal R18 650■■ Artificial disk - no benefit■■ Drug-eluting stents - no benefit■■ Mesh R6 800■■ Gynaecology/Urology R5 650■■ Lens implants R3 900 per lens

Sub-limits per beneficiary:■■ Functional R12 500■■ Vascular R29 150■■ Pacemaker (dual chamber) R39 450 ■■ Spinal R29 150■■ Artificial disk R12 800■■ Drug-eluting stents R12 800■■ Mesh R12 800■■ Gynaecology/Urology R9 500■■ Lens implants R8 150 per lens■■ Joint replacements:

■− Hip replacement and other major joints R34 800■− Knee replacement R40 700■− Minor joints R15 150

Prosthesis – External No benefit. Limited to R19 150 per family.


Joint replacement surgery (except for PMBs). PMBs subject to prosthesis limits:■■ Hip replacement and other major joints R19 150■■ Knee replacement R24 200■■ Minor joints R9 050

Not applicable.

Orthopaedic and medical appliances 100% Scheme tariff. Limited to R4 850 per family. 100% Scheme tariff.




Oncology DSP: State Facilities. Oncology programme. 100% Scheme tariff.

Oncology programme. 100% Scheme tariff.

Peritoneal dialysis and haemodialysis 100% Scheme tariff. National Renal Care. (NRC)


Refractive surgery No benefit. 100% Scheme tariff. Limited to R7 000 per eye.

In-hospital benefitsAll benefits below are subject to pre-authorisation and clinical protocols and designated hospital networks. Co-payments up to a maximum of R10 000 per event for voluntary use of a non-DSP hospital will be charged.

Pul

se


Pulse1 Pulse2Midwife-assisted births 100% Scheme tariff.




Co-payments Co-payment where procedure has been clinically approved: ■■ R2 800 on all laparoscopic procedures, ■■ R2 800 on prostate procedures, ■■ R2 800 on procedures for prolapse/incontinence, ■■ R2 800 on arthroscopy other than acute trauma, ■■ R2 800 on endoscopy investigations done

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

voluntary use of a non-DSP hospital.

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

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

network provider, CareCross, covers most out-of-hospital services. Some preventative care services are available from Scheme risk benefit.

In-hospital services are paid from Scheme risk benefit. The designated network provider, OneCare, covers most out-of-hospital services.

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

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

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


Treatment of chemical and substance abuse 100% Scheme tariff. (Only PMBs). 100% Scheme tariff.Limited to 21 days or R24 000 per beneficiary.

Subject to network facilities.


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

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

stimulators are used.

100% Scheme tariff.



No benefit. 100% Scheme tariff.

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





Note: Sub-limit subject to the above prosthesis limit


Sub-limits per beneficiary:■■ Functional R8 000■■ Vascular R18 650■■ Pacemaker (dual chamber) R30 500■■ Endovascular - no benefit■■ Spinal R18 650■■ Artificial disk - no benefit■■ Drug-eluting stents - no benefit■■ Mesh R6 800■■ Gynaecology/Urology R5 650■■ Lens implants R3 900 per lens

Sub-limits per beneficiary:■■ Functional R12 500■■ Vascular R29 150■■ Pacemaker (dual chamber) R39 450 ■■ Spinal R29 150■■ Artificial disk R12 800■■ Drug-eluting stents R12 800■■ Mesh R12 800■■ Gynaecology/Urology R9 500■■ Lens implants R8 150 per lens■■ Joint replacements:

■− Hip replacement and other major joints R34 800■− Knee replacement R40 700■− Minor joints R15 150

Prosthesis – External No benefit. Limited to R19 150 per family.


Joint replacement surgery (except for PMBs). PMBs subject to prosthesis limits:■■ Hip replacement and other major joints R19 150■■ Knee replacement R24 200■■ Minor joints R9 050

Not applicable.

Orthopaedic and medical appliances 100% Scheme tariff. Limited to R4 850 per family. 100% Scheme tariff.






Peritoneal dialysis and haemodialysis 100% Scheme tariff. National Renal Care. (NRC)


Refractive surgery No benefit. 100% Scheme tariff. Limited to R7 000 per eye.

All benefits below are subject to pre-authorisation and clinical protocols and designated hospital networks. Co-payments up to a maximum of R10 000 per event for voluntary use of a non-DSP hospital will be charged.


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

GP consultations Specialist consultations

Subject to CareCross Provider Network. Unlimited GP visits. Member must pay for services up-front and claim back from available out-of-network benefit.

Out-of-network visits with a GP limited to R1 050 per family per year.

Three specialist visits per family limited to R1 050 per visit. (Bestmed approval and tariff), pre-authorisation and referral by NP required.

Subject to OneCare Provider Network. Unlimited GP visits. Two out-of-network GP visits per family limited to

R1 150 as approved by NP. Specialist consultations must be referred and approved by NP. Specialist limited to M = R2 250, M1+ = R4 550.


Basic and specialised dentistry Basic dentistry: Subject to Provider Network.

Specialised dentistry: No benefit.

Basic: According to NP tariff list. 100% Scheme tariff. (Subject to overall day-to-day limit).

Specialised: 100% Scheme tariff, subject to pre-authorisation and day-to-day limit.Limited to M = R5 450, M1+ = R6 900.


No benefit. Limited to R7 700 per family. Limit on wheelchairs of R9 900 per family, per 48 months. Limit on hearing aids

of R21 400 per beneficiary per 24 months.

Supplementary services No benefit. Limited to M = R3 200, M1+ = R6 300. (Subject to overall day-to-day limit)


No benefit. Limited to R7 400 per family.

Optometry benefits (frames and lenses)

Subject to Provider Network. Protocols apply. Subject to Optical Management programme.Limited to M = R3 200, M1+ = R4 950.


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


Subject to Provider Network. Protocols and tariff list apply.

Referal by NP required.

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

Referal by NP required.

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

PET scans: 1 scan per beneficiary.



Rehabilitation services after trauma No benefit.

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

Pulse


Additional Scheme benefits on the Pulse options include international travel cover and preventative care.

We perceive trust as a fundamental requirement of life which originates from a commitment to approach all relationships with honesty and integrity.

Pulse1 Pulse2Preventative care Health Check and lifestyle screenings


■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations ■■ Health Check (Biometric screenings)

■■ Flu vaccines ■■ Pneumonia vaccines■■ Paediatric immunisations■■ DBC programme■■ Health Check (Biometric screenings)■■ Female contraceptives R1 550 per family

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

Preventative care benefitsNote: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and MRP/MMAP. DSPs may apply.

Pulse1 Pulse2CDL chronic medicine Unlimited. Subject to Provider Network Formulary and

reference price. 100% Scheme tariff. 35% co-payment on non-formulary medicine prescribed by a specialist.

Unlimited. Subject to Provider Network Formulary and reference price. 100% Scheme tariff.

25% co-payment on non-formulary medicine.

Non-CDL chronic medicine No benefit. 25 conditions. 100% Scheme tariff if prescribed by a NP. Limited to M = R6 800, M1+ = R13 500.



No benefit. Limited to R116 200 per beneficiary.

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

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

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

Over-the-counter (OTC) medicine Can be obtained from preferred provider pharmacy subject to CareCross OTC formulary.

This benefit is limited to 3 events per beneficiary or a maximum of 5 events per family per year.

Limited to R1 150 per family subject to acutemedicine formulary and reference price.

(Subject to overall day-to-day and acute medicine limit)

MedicineNote: Benefits mentioned below may be subject to pre-authorisation, formularies, funding guidelines and MRP/MMAP. DSPs may apply. Approved CDL and non-CDL chronic medicine costs will pay from the non-CDL chronic medicine limit first. Once the limit is depleted, CDL chronic medicine will continue to pay unlimited.

Pul

se


Pulse1 Pulse2Preventative care Health Check and lifestyle screenings


■■ Flu vaccines■■ Pneumonia vaccines■■ Paediatric immunisations ■■ Health Check (Biometric screenings)

■■ Flu vaccines ■■ Pneumonia vaccines■■ Paediatric immunisations■■ DBC programme■■ Health Check (Biometric screenings)■■ Female contraceptives R1 550 per family

Pulse1 Pulse2Reimbursement for CDL

100% Scheme tariff

Reimbursement for non-CDL

No benefit 100% Scheme tariff

Non-formulary co-payment

35% for non-formulary medicines prescribed by

a specialist25%

No. of non-CDL conditions covered

No benefit 25


CDL 2 Asthma












CDL 14 Dysrhythmia

CDL 15 Epilepsy

CDL 16 Glaucoma

CDL 17 Haemophilia

CDL 18 HIV/AIDS


CDL 20 Hypertension








The Chronic Disease List (CDL) provides cover for the 27 listed chronic conditions for which medical schemes must cover the diagnosis, medical management and medicines as published by the Council for Medical Schemes. Non-CDL chronic conditions are those additional conditions that Bestmed provides chronic medicine cover for. Authorisation for CDL and non-CDL chronic medicines is subject to clinical funding guidelines and protocols, formularies and Designated Service Providers (DSPs) where applicable. Below is the list of CDL and non-CDL conditions that Bestmed covers on the various benefit options. Note: Benefits mentioned below are subject to pre-authorisation, formularies, funding guidelines and MRP/MMAP. DSPs may apply.

Chronic conditions list (CDL & non-CDL)

Pulse1 Pulse2non-CDL 1 Acne - severe

non-CDL 2

Attention deficit disorder/Attention deficit

hyperactivity disorder (ADD/ADHD)


non-CDL 4 Eczema






non-CDL 10Polycystic ovarian

disease

non-CDL 11Obsessive compulsive

disorder

non-CDL 12 Stroke



non-CDL 15Benign prostatic

hypertrophy

non-CDL 16 Osteoporosis

non-CDL 17 Psoriasis

non-CDL 18 Urinary incontinence

non-CDL 19 Paget’s disease

non-CDL 20Gastro oesophageal

reflux disease (GORD)

non-CDL 21 Hypophyseal adenoma

non-CDL 22 Osteoarthritis

non-CDL 23 Alzheimer's disease

non-CDL 24 Aplastic anaemia

non-CDL 25 Neuropathy

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

Pulse


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

Contributions

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

Pulse1 Pulse2Income level R0 – R6 000 p.m. R6 001 – R10 000 p.m. > R10 001 p.m. N/A

PRINCIPAL MEMBER

Risk R1 131 R1 357 R1 630 R3 902

Savings R0 R0 R0 R0

Total R1 131 R1 357 R1 630 R3 902

ADULT DEPENDANT

Risk R1 075 R1 290 R1466 R3 902

Savings R0 R0 R0 R0

Total R1 075 R1 290 R1 466 R3 902

CHILD DEPENDANT

Risk R679 R814 R814 R927

Savings R0 R0 R0 R0

Total R679 R814 R814 R927

Maximum contribution child dependant*

Not applicable. 4


Not applicable. Under 21, unless a registered student.


Pul

se


Contributions Notes

086 000 2378

[email protected]

012 472 6500

www.bestmed.co.za

@BestmedSocial

www.facebook.com/ BestmedMedicalScheme

General contact details

WALK-IN FACILITY

Block A, Glenfield Office Park361 Oberon AvenueFaerie Glen, Pretoria, 0081, South Africa

POSTAL ADDRESS

P. O. Box 2297, Arcadia, Pretoria, 0001, South Africa

ER24 AND INTERNATIONAL TRAVEL COVER

Tel: 084 124

HOSPITAL AUTHORISATION

Tel: 080 022 0106E-mail: [email protected]

CHRONIC MEDICINE (BEAT AND PACE OPTIONS)

Tel: 086 000 2378E-mail: [email protected]: 012 472 6760

CLAIMS

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

SOCIAL MEDIA

Website: www.bestmed.co.zaFacebook: www.facebook.com/BestmedMedicalScheme Twitter: @BestmedSocial

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

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

CARECROSS HEALTH (PULSE OPTIONS ONLY)

Tel: 021 673 1848Website: www.carecross.co.zaFax: 021 413 1805

CARECROSS CHRONIC MEDICINE (PULSE OPTIONS ONLY)

Tel: 086 010 2182E-mail: [email protected]: 021 673 1815

CARECROSS BENEFIT CLAIMS (PULSE OPTIONS ONLY)


MATERNITY CARE


705485 Bestmed Comparative Guide 07/10/2015

This guide was printed in October 2015. For the most recent version of this guide,

please visit our website at www.bestmed.co.za © Bestmed Medical Scheme 2016 Bestmed Medical Scheme is a registered Medical Scheme (reg. no. 1252) and an Authorised Financial Services Provider (FSP no. 44058).

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