Benefit Summary 2019 PACE1 - CMAC Klerksdorp
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PACE1 Benefit Summary 2019
Method of benefit payment
On the Pace1 option in-hospital services are paid from the Scheme risk. Some MEDICAL EVENT SCHEME BENEFIT
out-of-hospital services are paid from the annual savings first and once depleted
Major medical maxillo-facial 100% Scheme tariff.
will be paid from the day-to-day benefit. Once the day-to-day benefit is depleted, surgery strictly related to Limited to R11 825 per family.
PACE1 services can be paid from the available vested savings. Some preventative care certain conditions
services are available from the Scheme risk benefit.
Dental and oral surgery Limited to R7 310 per family.
Prosthesis 100% Scheme tariff.
In-hospital benefits (Subject to preferred provider, Limited to R81 700 per family.
otherwise limits and co-
Note: payments apply)
• All in-hospital benefits referred to in the section below require pre-authorisation.
Please contact 080 022 0106 or e-mail authorisations@bestmed.co.za to obtain a
COMPREHENSIVE COVER pre-authorisation number.
PACE1 OPTION
(IN- AND OUT-OF-HOSPITAL) • Clinical protocols, preferred providers, designated service providers (DSPs),
Recommended for? You are a healthy, growing family and require excellent formularies, funding guidelines and the Mediscor Reference Price (MRP) may apply.
hospital benefits with extensive day-to-day cover. Pace1
is perfect for families who want quality benefits at MEDICAL EVENT SCHEME BENEFIT
affordable prices.
Accommodation (hospital stay) 100% Scheme tariff.
Contribution range R3 609 - Principal member and theatre fees
R2 534 - Adult dependant
R 911 - Child dependant Take-home medicine 100% Scheme tariff.
Limited to 7 days’ medicine. We are a Scheme
Savings account/Day- Savings account available.
to-day benefits Day-to-day benefits are available. Treatment in mental health
clinics
100% Scheme tariff.
Limited to 21 days per beneficiary. managed by members,
Value benefits No co-payment or automatic self-payment gaps.
FP and Specialist consultations. Treatment of chemical and 100% Scheme tariff. for members and will
Optometry. substance abuse Limited to 21 days or R29 240 per
Dentistry. beneficiary. Subject to network facilities. never compromise
Maternity benefits.
Consultations and procedures 100% Scheme tariff.
Over-the-counter Available. on quality service
Surgical procedures and 100% Scheme tariff.
medicine
anaesthetics to you.
Not recommended for? Families looking for more comprehensive and speciality
Organ transplants 100% Scheme tariff (only PMBs).
cover. Pace3 and 4 are the ideal options for you.
2 PACE1 PACE1 3
MEDICAL EVENT SCHEME BENEFIT MEDICAL EVENT SCHEME BENEFIT
Prosthesis – Internal Sub-limits per beneficiary: Confinements 100% Scheme tariff.
Note: Sub-limit subject to the • *Functional limited to R14 674
above prosthesis limit. • Vascular R29 777 Refractive surgery and all 100% Scheme tariff.
*Functional: Items utilised • Pacemaker (dual chamber) types of procedures to improve Limited to R8 127 per eye.
towards treating or supporting R50 848 or stabilise vision (excluding
a bodily function. • Endovascular and catheter-based cataracts)
procedures – no benefit
Midwife-assisted births 100% Scheme tariff.
• Spinal R29 777
• Artificial disc - no benefit Supplementary services 100% Scheme tariff.
• Drug-eluting stents - DSP
products only Alternatives to hospitalisation 100% Scheme tariff.
• Mesh R11 180
• Gynaecology/Urology R8 063 Emergency evacuation Services rendered by ER24.
• Lens implants R6 128 per lens per eye
Prosthesis – External Limited to R20 748 per family.
Exclusions Joint replacement surgery (except for
Limits and co-payments PMBs). PMBs subject to prosthesis limits:
applicable. • Hip replacement and other major joints
Preferred provider network R30 315
available. • Knee replacement R40 313
• Minor joints R12 524
Orthopaedic and medical 100% Scheme tariff.
appliances
Pathology 100% Scheme tariff.
Diagnostic imaging 100% Scheme tariff.
Specialised diagnostic imaging 100% Scheme tariff. We always
Oncology Oncology programme - PMBs only, make
use of Independent Clinical Oncology strive to
Network (ICON) as the DSP.
Peritoneal dialysis and PMBs only at DSPs.
exceed your
haemodialysis
expectations.
4 PACE1 PACE1 5
Out-of-hospital benefits MEDICAL EVENT SCHEME BENEFIT
Basic and specialised dentistry Savings first.
Note: Basic: Preventative benefit or savings account.
• Some indicated benefits are paid from the annual savings at 100% Scheme tariff. Limit once savings exceeded.
Specialised: Savings account then limit.
• Once the annual savings account is depleted benefits will be paid from Scheme risk Orthodontic: Subject to pre-authorisation.
at 100% Scheme tariff (limits apply). Limited to M = R3 740, M1+ = R7 590.
(Subject to overall day-to-day limit)
• Should you not use all of the funds available in your medical savings account these funds
will be transferred into a vested medical savings account at the beginning of the following Medical aids, apparatus 100% Scheme tariff.
financial year. and appliances including Savings first.
wheelchairs and hearing aids Limited to R10 428 per family.
• Any vested credit in your vested medical savings account may be used for out-of-hospital (Subject to overall day-to-day limit and hearing
expenses that are not covered by the Scheme, or should you, for instance, have reached aid every 24 months)
your out-of-hospital/day-to-day overall annual limit or the sub-limits as indicated in your
benefit guide. Supplementary services Savings first.
Limited to M = R3 988, M1+ = R8 278.
• Unused funds in your vested medical savings account at the end of the financial year will (Subject to overall day-to-day limit)
be carried over to the credit of your vested medical savings account for the next year.
Wound care benefit 100% Scheme tariff.
• Clinical funding protocols, preferred providers, designated service providers (DSPs), (incl. dressings, negative Savings first.
formularies, funding guidelines and the Mediscor Reference Price (MRP) may apply. pressure wound therapy Limited to R3 279 per family.
treatment and related nursing (Subject to overall day-to-day limit)
• If you have a treatment plan for a registered Chronic Disease List (CDL) and/or Prescribed services - out-of-hospital)
Minimum Benefit (PMB) condition/s, the services in the treatment plan will pay from the
applicable day-to-day limit first. Once the limit is depleted, claims will continue to be paid Optometry benefit Benefits available every 24 months from date
from Scheme risk, up to the maximum quantity specified in the treatment plan. (PPN capitation provider) of service.
Network Provider (PPN)
• Consultation - 1 free per beneficiary every
MEDICAL EVENT SCHEME BENEFIT 24 months.
• Frame = R825 covered AND
Overall day-to-day limit M = R9 868, M1+ = R19 737. • 100% of cost of standard lenses. (single vision/
bifocal/multifocal/contact lenses).
FP and specialist consultations Savings first. OR
Limited to M = R2 032, M1+ = R4 085. Non-network Provider
(Subject to overall day-to-day limit) • Consultation - R300 fee at non-network provider
• Frame = R550 AND
• Single vision lenses = R175 OR
• Bifocal lenses = R410 OR
• Multifocal lenses = R710 OR
• Contact lenses = R1 435
6 PACE1 PACE1 7
MEDICAL EVENT SCHEME BENEFIT Medicine Chronic Conditions List
Diagnostic imaging and 100% Scheme tariff. CDL
Note:
pathology Savings first.
Limited to M = R2 956, M1+ = R5 913. Benefits below may be subject to pre-authorisation, clinical protocols, formularies, CDL 1 Addison's disease
(Subject to overall day-to-day limit) funding guidelines and the Mediscor Reference Price (MRP).
CDL 2 Asthma
Maternity benefits 100% Scheme tariff.
*Please note that the approved CDL, PMB and non-CDL chronic medicine costs will be paid from the
• 9 x antenatal consultations at either FP/ CDL 3 Bipolar mood disorder
non-CDL limit first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid
These benefits are unlocked Gynaecologist/Midwife. (unlimited) from Scheme risk.
CDL 4 Bronchiectasis
by completing a Health Risk • 1x 2D ultrasound nuchal translucency scan at
Assessment at a contracted 10-12 weeks at Gynaecologist. CDL 5 Cardiomyopathy
pharmacy. • 1x 2D ultrasound scan at 20-24 weeks at
BENEFIT DESCRIPTION SCHEME BENEFIT
Gynaecologist. CDL and PMB chronic medicine* 100% Scheme tariff. Co-payment of 35% CDL 6 Chronic renal disease
• 1x 2D ultrasound scan first trimester at for non-formulary medicine.
radiologist. CDL 7 Chronic obstructive pulmonary disease (COPD)
• 1x 2D ultrasound scan second trimester at Non-CDL chronic medicine* 7 conditions. 85% Scheme tariff.
CDL 8 Cardiac failure
radiologist. Limited to M = R6 020,
• Antenatal iron supplements (9 fills). M1+ = R12 040. Co-payment of 35% for CDL 9 Coronary artery disease
• Antenatal folic acid (9 fills). non-formulary medicine.
• Please ensure that tests you undergo are CDL 10 Crohn's disease
covered. Tests, including urine dipstick tests Biologicals and other high-cost No benefit.
medicine CDL 11 Diabetes insipidus
and other tests are covered.
• 1x post-natal consultation at FP/ Acute medicine Savings first. CDL 12 Diabetes mellitus type 1
Gynaecologist/Midwife. Limited to M = R2 129, M1 + = R4 408.
(Subject to overall day-to-day limit) CDL 13 Diabetes mellitus type 2
Specialised diagnostic imaging 100% Scheme tariff.
Limited to R13 223 per family. Over-the-counter (OTC) *Member choice: 1. R550 OTC limit OR CDL 14 Dysrhythmias
Rehabilitation services after Vested savings. medicine 2. Access to full PMSA for OTC purchases CDL 15 Epilepsy - severe
trauma See benefit option rules (after R550 limit) = self-payment gap
accumulation. CDL 16 Glaucoma
Oncology Oncology programme - PMBs only, make use of
Independent Clinical Oncology Network (ICON) as CDL 17 Haemophilia
*The default OTC choice is 1. R550 OTC limit. Members wishing to choose the other option are
the DSP.
welcome to contact Bestmed. CDL 18 Hyperlipidaemia
Peritoneal dialysis and Subject to pre-authorisation and DSPs.
CDL 19 Hypertension
haemodialysis
CDL 20 Hypothyroidism
CDL 21 Multiple sclerosis
8 PACE1 PACE1 9
CDL PMB Preventative Care benefits
CDL 22 Parkinson’s disease PMB 7 Female menopause
Note:
CDL 23 Rheumatoid arthritis PMB 8 Fibrosing alveolitis
Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP).
CDL 24 Schizophrenia PMB 9 Graves’ disease
CDL 25 Systemic lupus erythematosus (SLE) PMB 10 Hyperthyroidism
PREVENTATIVE CARE BENEFIT GENDER AND AGE GROUP QUANTITY AND FREQUENCY BENEFIT CRITERIA
Flu vaccines All ages. 1 per beneficiary per year. Applicable to all active members
CDL 26 Ulcerative colitis PMB 11 Hypophyseal adenoma
and beneficiaries.
PMB 12 Idiopathic thrombocytopenic purpura
NON-CDL Pneumonia vaccines Children
PREVENTATIVE CARE BENEFIT GENDER AND AGE GROUP QUANTITY AND FREQUENCY BENEFIT CRITERIA
Mammogram Females 40 years and older. Once every 24 months. Scheme tariff is applicable.
HPV vaccinations Females of 9-26 years old. 3 vaccinations per beneficiary. Vaccinations will be funded at MRP.
Pap smear Females 18 years and older. Once every 24 months. Can be done at a gynaecologist
or FP. Consultation paid from the
available savings/consultation
benefit.
Bestmed Wellness Programme Health Risk Assessment (biometric screening) at contracted pharmacy.
1 per beneficiary per year (age 21+).
Note: Completing your Health Risk • Fitness assessment at a contracted biokineticist: 1 per beneficiary per year (age 13+), thereafter 3 biokineticist
Assessment unlocks the other Wellness consultations per beneficiary per year. Pre-approval required.
Programme benefits. • Nutritional assessment: 1 per beneficiary per year (age 18+), thereafter 3 dietician consultations per beneficiary
per year. Pre-approval required.
• Occupational therapy assessment: 1 per beneficiary per year (ages 3-13 years).
• Baby growth assessment: At a contracted pharmacy clinic, 3 per beneficiary per year (ages 0-35 months).
Disclaimer: General and option-specific exclusions apply. Please refer to www.bestmed.co.za for more details.
Midwife-assisted
births are covered
at 100% of
Scheme tariff on
all Pace options.
12 PACE1 PACE1 13
Maternity Care programme Preventative dentistry Contributions
Finding out you are pregnant comes with a whole lot of emotions, questions and Note: PRINCIPAL ADULT CHILD
information. Sometimes just knowing where to start and which information you Services mentioned below may be subject to pre-authorisation, clinical protocols MEMBER DEPENDANT DEPENDANT*
can trust can be a challenge. and funding guidelines. Risk amount R2 923 R2 053 R738
Pregnant members and dependants have access to the Maternity Care programme.
The programme provides comprehensive information and services and was DESCRIPTION Savings amount R686 R481 R173
AGE FREQUENCY
designed with the needs of expectant parents and their support network in OF SERVICE Total monthly
mind. We aim to give you support, education and advice through all stages of your R3 609 R2 534 R911
contribution
General full-mouth Above 12 years. Once a year.
pregnancy, the confinement and postnatal (after birth) period.
examination by a Under 12 years. Twice a year.
After registering on this programme and going for a Health Risk general dentist * You only pay for a maximum of four children. All other children can join as beneficiaries of the Scheme
Assessment (HRA) you will receive: (incl. gloves and use free of charge.
of sterile equipment
• A welcome pack containing an informative pregnancy book about the stages
for the visit)
of pregnancy.
Full-mouth intra-oral All ages. Once every
• Discount vouchers.
radiographs 36 months.
• A beautiful baby bag. (Sent by month 5 of your pregnancy. You will receive an SMS.)
Intra-oral radiograph All ages. 2 photos per year.
• Various baby items.
Scaling and/or polishing All ages. Twice a year.
• Access to a 24-hour medical advice line.
Fluoride treatment All ages. Twice a year.
• Benefits through each phase of your pregnancy.
Fissure sealing Up to and including In accordance with
How to register: 21 years. accepted protocol. For a more detailed
Space maintainers During primary and Once per space.
Send an e-mail to maternity@bestmed.co.za or call us on 012 472 6243.
Please include your contact details (postal/delivery addresses), your medical mixed denture stage. overview of your
scheme number and your expected delivery date in the e-mail.
Go for a Health Risk Assessment (HRA) at any network pharmacy to finalise Disclaimer: General and option-specific exclusions apply.
benefit option and to
your registration. Please refer to www.bestmed.co.za for more detail.
receive a membership
guide please contact
Abbreviations
CDL = Chronic Disease List; DBC = Documentation Based Care (back rehabilitation programme);
service@bestmed.co.za
FP = Family Practitioner or Doctor; HPV = Human Papilloma Virus; M = Member; M1+ = Member and
family; MRP = Mediscor Reference Price; NPWT = Negative Pressure Wound Therapy; PMSA = Personal
Medical Savings Account; PMB = Prescribed Minimum Benefits; PPN = Preferred Provider Negotiators.
14 PACE1 PACE1 15086 000 2378
service@bestmed.co.za
012 472 6500
www.bestmed.co.za
@BestmedScheme
www.facebook.com/
BestmedMedicalScheme
HOSPITAL AUTHORISATION WALK-IN FACILITY BESTMED HOTLINE, OPERATED BY KPMG
Tel: 080 022 0106 Block A, Glenfield Office Park, Should you be aware of any fraudulent, corrupt or unethical
E-mail: authorisations@bestmed.co.za 361 Oberon Avenue, Faerie Glen, practices involving Bestmed, members, service providers or
CHRONIC MEDICINE Pretoria, 0081, South Africa employees, please report this anonymously to KPMG.
Tel: 086 000 2378 POSTAL ADDRESS
E-mail: medicine@bestmed.co.za PO Box 2297, Arcadia, Hotline: 080 111 0210 toll-free from any Telkom line
Fax: 012 472 6760 Pretoria, 0001, South Africa
Hotfax: 080 020 0796
CLAIMS ER24
Tel: 086 000 2378 Tel: 084 124 Hotmail: fraud@kpmg.co.za
E-mail: service@bestmed.co.za (queries) INTERNATIONAL TRAVEL INSURANCE
claims@bestmed.co.za (claim submissions) (BRYTE INSURANCE) Postal: KPMG Hotpost, at BNT 371,
MATERNITY CARE Tel: 0860 329 329 (RSA only) during PO Box 14671, Sinoville,
Tel: 012 472 6243 office hours / 084 124 after hours 0129, South Africa
E-mail: maternity@bestmed.co.za E-mail: er24@brytesa.com
Claims: travelclaims@brytesa.com
For a more detailed overview of your benefit option and to receive a membership guide please contact service@bestmed.co.za
Disclaimer: All the 2019 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 2019 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 note
that should a dispute arise, the registered Rules, as approved by the Registrar of Medical Schemes, shall prevail.
Please visit www.bestmed.co.za for the complete liability and responsibility disclaimer for Bestmed Medical Scheme as well as our terms and conditions.
Bestmed Medical Scheme is a registered medical scheme (Reg. no. 1252) and an Authorised Financial Services Provider (FSP no. 44058). ©Bestmed Medical Scheme 2018.
13267 Bestmed Brochure A5 ENG_Pace1. This brochure was printed in October 2018. For the most recent version please visit our website at www.bestmed.co.zaYou can also read
