Comparative Guide 2020 - Classique Medical Aid ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Comparative Guide 2020
5 017
When life happens…
MEMBERS ON
THE BESTMED
ONCOLOGY
We are here to assist you! PROGRAMME
Contents
REGISTERED
MOMS ON
6 372
BESTMED THE BESTMED
BABIES BORN MATERNITY MEMBERS REGISTERED ON
PROGRAMME THE BESTMED DIABETIC
PROGRAMME
PERSONALLY YOURS 3 Out-of-hospital benefits 13
Why Bestmed should be your medical aid of choice 3 Medicine 14
All you need to know about Bestmed Tempo 4 Preventative care benefits 15
MEMBERS DID
Contributions 15 FREE HEALTH
BEAT 5 RISK ASSESSMENTS
Method of Scheme benefit payment 6 PULSE 16
In-hospital benefits 6 Method of Scheme benefit payment 16
Out-of-hospital benefits
Medicine
Preventative care benefits
8
9
10
In-hospital benefits
Out-of-hospital benefits
Medicine
16
17
18
4 683
Contributions 11 Preventative care benefits 19 MEMBERS REGISTERED ON
THE BESTMED HIV/AIDS
Contributions 19
PACE 11 PROGRAMME
Method of Scheme benefit payment 12 CHRONIC DISEASE LIST 21
In-hospital benefits 12
2 COMPARATIVE GUIDE 2020
Why Bestmed should be your medical aid of choice
Additional Benefits
Students are eligible for child dependent rates up to 26 years of age.
We provide value for money
Extensive maternity benefits.
Single digit increases over 11 consecutive years.
Health management support programmes include a diabetes programme (HaloCare),
Our administration costs are between 3 - 5 % cheaper than our competitors maternity care programme, oncology programme and HIV/AIDS programme
because we are self-administered.
Our plan options have 75% less co-payments, compared to our competitors. FREE access to the Tempo wellness programme
We have 13 structured plans, designed to suit every life stage and pocket. with benefits worth up to R4,500
No automatic self-payment gap on any of our options.
Excellent preventative care benefits on all our options e.g. female Our wellness programme is free for all members and employers.
contraceptives, pneumonia and flu vaccines and more...
Includes free Health Risk Assessments, visits to dieticians and to biokineticists.
Also family interventions, family workshops and baby growth assessments.
An excellent track record
We have been offering medical aid since 1964.
Don’t worry, be Appy!
We are the largest self-administered scheme in South Africa and the fourth
largest open medical scheme. The Bestmed App is just one more way that Bestmed is Personally Yours. It’s user-friendly,
and has been designed to put all your essential medical information at your fingertips. To
Four of our options have been selected as the best performers within the
make the most of the new features, remove the old App from your phone and download the
South African medical scheme market (2018 GTC Medical Aid Survey).
new version from the App Store or Google Play.
We have been voted third on the client service satisfaction benchmark by
the Ask Africa Orange Index 2018. You’ll notice that the updated App has a
We have a solvency ratio of 32.8%. new icon, and an easy-to-use slide-out
menu that lets you:
There are about 200 000 lives under our care.
Download your tax certificate.
Get automatic updates on Scheme
An extensive service provider network communications.
Find information on all benefits.
Access to specialist and hospital networks across South Africa.
More than 4 000 family practitioners in our network. Update your personal details.
More than 14 500 network provider agreements. Submit your chronic medication claims.
Country-wide geographical network coverage.
Search for a specialist in your area.
Search facility via the Bestmed app and website.
COMPARATIVE GUIDE 2020 3
All you need to know about Bestmed Tempo
WHAT IS BESTMED TEMPO?
Tempo is our preventative care programme. It’s a package of benefits and offerings which
gives you access to expert healthcare professionals. Their advice and assistance will help
you understand your health risks and improve your quality of life.
WHY SHOULD I JOIN THE PROGRAMME?
The programme is included in your monthly subscription. It already forms part of your
benefit structure and is available to you and your family at no additional cost. By making
use of the programme’s benefits you get access to experts who can assist you with practical
and reliable advice which will help you change your lifestyle and become the best version
of yourself.
HOW DO I ACTIVATE THE PROGRAMME?
You need to go for a health risk assessment (HRA) at a wellness contracted network
pharmacy or you can have it done at your place of employment during a wellness day. Once
we’ve received the results of your HRA your Tempo benefits are immediately unlocked.
WHICH BENEFITS ARE INCLUDED IN THE PROGRAMME?
Tempo benefits start with a free HRA which is available to you and your dependants (18 and
older). We also offer a range of screenings and assessments for dependants aged between
13 and 17 which includes:
A health assessment at a biokineticist.
A functional assessment at an occupational therapist .
We also offer baby growth and development assessments from a qualified nurse within a
pharmacy clinic for those yournger than 3.
Once you have the results of your screenings and assessments your family will have access
Set your TEMPO to a nutritional assessment at a dietician. In addition to this, adult beneficiaries (18 and
older) can also go to a biokineticist three times per year. This will help you determine your
current fitness levels as well as help you to plan how to incorporate fitness and activity into
with a FREE your daily lives.
Health Risk Simultaneously, adult beneficiaries also have access to three consultations with a dietician
who will assist you in making healthier food choices.
Assessment, The programme also includes access to a number of group interventions and group sessions
for all ages aimed at encouraging healthier lifestyle choices. The group interventions are
not a smoothie! advertised throughout the year in the different regions.
HOW DO I ACCESS AND UTILISE THE PROGRAMME’S BENEFITS?
Once you’ve done your HRA at a contracted pharmacy you’ll unlock all the other benefits
included in the programme. Invitations to the group interventions or Healthy Living
workshops are also limited to those who have done their HRAs.
4 COMPARATIVE GUIDE 2020
HOW WILL I, OR MY FAMILY MEMBERS, BENEFIT FROM THE PROGRAMME?
We regard family as the most important core unit when choosing to live a healthier life. It’s
no use focusing on mom and dad but neglecting to include their children in interventions and
discussions. For that reason we’ve started workshops aimed at children too.
In future, based on the number of young beneficiaries who went for their assessments since
the start of the programme – interventions aimed at young beneficiaries can be developed
and included in the benefit structure. Interventions for younger beneficiaries may be added
to Tempo at a later stage depending on how many young dependants have completed their
HRAs. BEAT
HOW DOES THIS PROGRAMME DIFFER FROM OTHER WELLNESS PROGRAMMES?
Firstly, the benefit package is included as part of your preventative care benefits. Secondly,
the programme is aimed at the individual within the family structure. Although the
benefits are available to everyone the advice and assistance that professional healthcare
practitioners provide is aimed at you only – so it’s an individualised programme and offering.
It’s not a one-size-fits-all programme and benefits package.
ARE THE BENEFITS ENTIRELY FREE?
Yes. They’re included in the monthly subscription you already pay as a member.
WILL THE PROGRAMME IMPROVE MY HEALTH/LIFE?
Definitely, provided that you make use of the advice and information the specialists provide
you with.
ARE THERE ANY ADDITIONAL BENEFITS FOR CHILDREN OR PREGNANT WOMEN?
You need to register on the Bestmed Maternity Care programme after your first trimester
(12 weeks). After registering your health risk assessment (HRA) will be scheduled. If you are
experiencing a high-risk pregnancy, the information will be sent to our case managers, and
they will help monitor your progress.
If an occupational therapist identifies your child as a high-risk candidate you can liaise
with us for additional benefits according to a treatment plan. This will assist you and your
family in attending to the needs and risks of your child. No child is alike and we’ll rely on the
advice and proposed treatment plan that the provider will submit to us prior to authorising
the additional consultations. Once we have enough information, we’ll develop treatment
protocols which are relevant to children.
Choose a
DOES THE PROGRAMME OFFER SUPPORT GROUPS?
Yes. We’ve commenced with a number of support groups aimed at dealing with
network option
childhood obesity. If you wish to be included in these projects please send an email to for lower
tempo@bestmed.co.za or Elmarie.Jooste@bestmed.co.za. Any other suggestions
regarding support group topics or themes are welcome.
contributions on
Beat!
DO THE FREE BENEFITS DIFFER FOR MEMBERS ON DIFFERENT HEALTHCARE OPTIONS?
No. The 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
COMPARATIVE GUIDE 2020 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. Treatment in mental 100% Scheme tariff. Limited to 21 days per beneficiary.
health clinics
Method of Scheme benefit payment Treatment of
chemical and
100% Scheme tariff. Limited to 21 days or R30 760 per beneficiary. Subject to
network facilities.
substance abuse
BEAT1 BEAT2 BEAT3 BEAT4
Consultations and 100% Scheme tariff. DSP specialist network applicable if the 100% Scheme
• In-hospital benefits are • In-hospital benefits are • In-hospital benefits are • In-hospital benefits are procedures Network option is chosen. tariff.
paid from Scheme risk. paid from Scheme risk. paid from Scheme risk. paid from Scheme risk.
• Some preventative care • Some preventative care • Some out-of-hospital • Some out-of-hospital Surgical procedures 100% Scheme tariff.
benefits are available benefits are available benefits are paid from benefits are paid from and anaesthetics
from Scheme risk. from Scheme risk. Scheme risk and some your medical savings Organ transplants 100% Scheme tariff (PMBs only).
• Out-of-hospital benefits • Out-of-hospital benefits from your medical account first, once
are paid from your own are paid from your savings account. depleted, from your day- Major medical No benefit. 100% Scheme 100% Scheme
pocket. medical savings account. • Some preventative care to-day benefit. maxillofacial surgery (PMBs only at DSP day hospitals). tariff. Limited to tariff. Limited to
benefits are available • Some preventative care strictly related to R12 327 per family. R12 554 per family.
certain conditions
from Scheme risk. benefits are available
from Scheme risk. Dental and oral PMBs only at DSP Qualifying PMB Limited to Limited to
surgery day hospitals. procedures only at R7 690 per family. R9 613 per family.
• Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs, this will not
DSP day hospitals.
affect your savings (annual or vested) for applicable options. Pulp procedures,
extractions and
restorations in
BEAT NETWORK PLAN OPTION DSP day hospitals
• Bestmed offers members a choice of network hospitals for in-hospital benefits. (only disabled
beneficiaries
• If a member voluntarily chooses not to make use of a hospital within the Beat network, a maximum co-payment of and beneficiaries
R11 309 will apply for the use of a non-designated service provider. aged 0 – 7 years) –
limited to R5 000
• The Family Practitioner (FP) consultation benefit is limited to Bestmed network providers.
per family.
• Specialist consultations are limited to Bestmed designated service providers.
Prosthesis 100% Scheme tariff. 100% Scheme 100% Scheme
(subject to preferred Limited to R75 092 per family. tariff. Limited to tariff. Limited to
providers and DSPs, R75 884 per family R92 629 per family.
In-hospital benefits otherwise limits and
co-payments apply)
The Non-Network option provides you with access to any hospital of your choice. This is the standard option. The
Network option provides you with a list of designated hospitals for you to use and also saves on your monthly
contribution.
Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs, this will not
affect your savings.
Note: Benefits mentioned below are subject to pre-authorisation and clinical protocols.
BEAT1 BEAT2 BEAT3 BEAT4
Accommodation 100% Scheme tariff. DSP specialist network applicable if the 100% Scheme
(hospital stay) and Network option is chosen. tariff.
theatre fees
Take-home medicine 100% Scheme tariff. Medicine limited to 7 days.
6 COMPARATIVE GUIDE 2020
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 R13 434. beneficiary: beneficiary: diagnostic imaging tariff.
Note: Sub-limit • Vascular R29 971. • *Functional • *Functional
subject to the above Oncology PMBs only at DSPs.
• Pacemaker (dual chamber) limited to limited to
prosthesis limit. R16 172.
R40 939. R13 435. Peritoneal dialysis PMBs only at DSPs. 100% Scheme
• Endovascular and catheter-based • Vascular • Vascular and haemodialysis tariff. Subject to
*Functional:
procedures – no benefit. R30 082. R32 005. pre-authorisation.
Items utilised
towards treating or • Spinal R29 971. • Pacemaker • Pacemaker
Confinements 100% Scheme tariff.
supporting a bodily • Artificial disk – no benefit. (dual chamber) (dual chamber) (Birthing)
function. • Drug-eluting stents – PMBs and DSP R40 939. R53 605.
products only. • Endovascular and • Endovascular and HIV / AIDS PMBs only at DSPs. 100% Scheme tariff. Subject to pre-authorisation and DSPs.
• Mesh R10 518. catheter-based catheter-based
Refractive surgery PMBs only. 100% Scheme 100% Scheme
• Gynaecology/Urology R8 595. procedures – no procedures – and all types of tariff. Subject to tariff. Subject to
• Lens implants R6 559 per lens per eye. benefit. no benefit. procedures to pre-authorisation pre-authorisation
• Spinal R30 082. • Spinal R32 005. improve or stabilise and protocols. and protocols.
• Artificial disk – no • Artificial disk – vision (except Limited to R7 916 Limited to R8 935
benefit. no benefit. cataracts) per eye. per eye.
• Drug-eluting • Drug-eluting
Midwife-assisted 100% Scheme tariff.
stents – PMBs stents R17 982.
births
and DSP products • Mesh R11 875.
only. • Gynaecology/ Supplementary 100% Scheme tariff.
• Mesh R10 573. Urology R8 708. services
• Gynaecology/ • Lens implants
Alternatives to 100% Scheme tariff.
Urology R8 732. R6 785 per lens hospitalisation
• Lens implants per eye.
R6 559 per lens Emergency Services rendered by ER24.
evacuation
per eye.
International travel Up to R10 million and a maximum of 90 days. Services rendered by Bryte Insurance
Prosthesis – External No benefit (PMBs only). Limited to R22 279 cover and managed by ER24.
per family.
Co-payments Co-payment of R3 619 on all Co-payment of Not applicable.
Exclusions Joint replacement surgery Joint replacement Joint replacement endoscopic investigations and R3 619 on all
(Prosthesis sub-limit (except for PMBs). surgery (except for surgery (except for specialised diagnostic imaging if done endoscopic
subject to preferred PMBs). PMBs). in a private hospital. Any other facility, investigations if
provider, otherwise PMBs subject to prosthesis limits:
• Hip replacement and other major joints PMBs subject to no co-payment. done in a private
limits and co- PMBs subject to hospital. Any other
payments apply) R31 553. prosthesis limits: prosthesis limits:
• Hip replacement facility, no co-
• Knee replacement R38 903. • Hip replacement payment.
• Minor joints R12 101. and other major and other major
joints R31 779. joints R32 910.
• Knee • Knee replacement
replacement R43 721.
R39 322. • Other minor joints
• Other minor joints R13 434.
R12 101.
Orthopaedic and 100% Scheme tariff.
medical appliances
Pathology 100% Scheme tariff.
Basic radiology 100% Scheme tariff.
COMPARATIVE GUIDE 2020 7
Out-of-hospital benefits
Note: Benefits below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service
providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP).
Approved PMB’s will be paid from scheme risk.
BEAT1 BEAT2 BEAT3 BEAT4
Overall day-to-day limit Not applicable. M = R12 214,
M1+ = R24 427.
Family Practitioner No benefit. Savings account. FP and specialist Savings first.
(FP) and specialist consultations only at Bestmed DSPs Limited to
consultations at network tariffs. M = R3 110,
M1+ = R5 541.
(Subject to
overall day-to-
6 inches
day limit)
Diabetes primary care 100% of Scheme tariff subject to registration with HaloCare.
consultation 2 primary care consultations at Dis-Chem Pharmacies limited to R341.90 per
consultation.
Beat4 option: Paid first from the “FP and specialist consultations” day-to-day
of fashion
can become
benefit, thereafter Scheme risk.
Basic and specialised No benefit. Basic: Preventative benefit or savings Savings first.
dentistry account. Limited to
Specialised: Savings account.
M = R5 381,
M1+ =
R10 808.
6 weeks on
Orthodontic: Subject to pre-
crutches!
authorisation. (Subject to
overall day-
to-day limit).
Orthodontics are
subject to pre-
authorisation.
Medical aids, apparatus No benefit. Savings account. Savings first.
and appliances 100% Scheme
including wheelchairs tariff. Limited
and hearing aids to R10 970 per
family. (Subject
Hearing aids are subject to overall day-to-
to pre-authorisation. day limit)
Supplementary services No benefit. Savings account. Savings first.
Limited to
M = R4 750,
M1+ = R9 647.
(Subject to
overall day-to-
day limit)
8 COMPARATIVE GUIDE 2020
BEAT1 BEAT2 BEAT3 BEAT4 Medicine
Wound care benefit 100% Scheme tariff. Savings first.
(incl. dressings, negative Limited to R 3 359 per family. 100% Scheme Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers,
pressure wound therapy tariff. Limited designated service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP). Approved
-NPWT- treatment and to R4 750 per CDL, PMB and non-CDL chronic medicine costs will be paid from the non-CDL chronic medicine limit first. Thereafter,
related nursing services family. (Subject approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
-out-of-hospital) to overall
Pre-approval for medicine can be obtained from medicine@bestmed.co.za or 086 000 2378.
day-to-day limit)
Note: Refer to the Chronic Conditions List at the back of the Comparative Guide.
Optometry benefit No benefit. Savings account. Benefits available every 24 months
(PPN capitation provider) from date of service.
Network Provider (PPN)
BEAT1 BEAT2 BEAT3 BEAT4
Consultation - 1 per beneficiary. CDL & PMB 100% Scheme tariff. Co-payment of 40% for non-formulary 100% Scheme tariff.
Frame = R868 covered AND chronic medicine. Co-payment of 30%
100% of cost of standard lenses medicine for non-formulary
(single vision OR bifocal OR multifocal) medicine.
OR Contact lenses = R1 510
OR Non-CDL No benefit. 5 conditions. 9 conditions.
Non-network Provider chronic 80% Scheme tariff. 90% Scheme tariff.
Consultation - R316 fee at non- medicine Limited to Limited to
network provider Frame = R579 AND M = R3 280, M = R7 204,
Single vision lenses = R184 OR M1+ = R6 673. M1+ = R14 408.
Bifocal lenses = R431 OR Co-payment of 35% Co-payment of 25%
Multifocal lenses = R747 OR for non-formulary for non-formulary
Contact lenses = R1 510 medicine. medicine.
Basic radiology No benefit. Savings account. Savings first. Biologicals PMBs only as per funding protocol.
and pathology Limited to and other Subject to pre-approval.
M = R3 110, high-cost
M1+ = R6 333. medicine
(Subject to
overall day-to- Acute No benefit. Savings account. Savings first.
day limit) medicine Limited to
M = R2 748,
Specialised diagnostic 100% Scheme tariff. 100% Scheme 100% Scheme M1+ = R5 552.
imaging Limited to R5 089 per family, tariff. Limited tariff. Limited to (Subject to overall
(excluding PET scans). to R10 688 per R16 172 per day-to-day limit)
family (excluding family.
PET scans). Over-the- No benefit. Savings account. *Member choice:
counter (OTC) Subject to available savings. 1. R650 OTC limit
Oncology PMBs only at DSPs. medicine OR
2. Access to full
Peritoneal dialysis and PMBs only at DSPs. 100% Scheme Includes savings for OTC
haemodialysis tariff. Subject to sunscreen, purchases (after
pre-authorisation. vitamins and R650 limit) =
minerals with self-payment gap
HIV / AIDS PMBs only at 100% Scheme tariff. Subject to pre-authorisation and DSPs.
nappi codes accumulation.
DSPs.
on Scheme Subject to
Rehabilitation services No benefit. Savings account. Vested savings. formulary available savings.
after trauma
*The Default OTC choice is 1. R650 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.
COMPARATIVE GUIDE 2020 9
Preventative care benefits BEAT1 BEAT2 BEAT3 BEAT4
Tempo Individual Health Risk Assessments (Adults aged 18 and older) – Biometric screening
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers,
Programme and lifestyle questionnaire to be completed at a network pharmacy or onsite at selected
designated service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP). (Wellness) employers (1 per year).
Note: Completing Child dependant assessments
your Health Risk
BEAT1 BEAT2 BEAT3 BEAT4 • Ages 13-17 years: Assessment done by a contracted biokineticist (wellness network
Assessment
provider) – 1 per beneficiary per year.
(HRA) unlocks
Preventative care • Flu vaccines. • Flu vaccines. • Flu vaccines. • Flu vaccines. • Ages 3-12 years: Assessment done by a contracted occupational therapist (wellness
the other Tempo
benefits • Pneumonia • Pneumonia • Pneumonia • Pneumonia network provider) – 1 per beneficiary per year.
benefits.
vaccines. vaccines. vaccines. vaccines. One parent • Ages 0-2 years: Baby growth and development assessments done at a contracted
Note: Refer to • Female • Paediatric • Paediatric • Paediatric must complete pharmacy clinic – 3 assessments per year.
Scheme rules for immunisations.
contraceptives – immunisations. immunisations. their HRA in Family assessments - Nutrition
funding criteria
R2 205 per • Female • Female • Female order to unlock • Family nutritional assessment done at a contracted dietician (wellness network provider)
applicable to each
beneficiary per contraceptives – contraceptives – contraceptives – assessments – 1 per family per year.
preventative
year. R2 205 per R2 205 per R2 205 per for beneficiaries
care benefit. Fitness and nutritional interventions (beneficiaries 18 and older)
• Back and neck beneficiary per beneficiary per beneficiary per younger than 18.
• 3 individualised consultations per year at a contracted biokineticist (wellness provider
preventative year. year. year. network).
programme. • Back and neck • Back and neck • Back and neck • 3 individualised consultations per year at a contracted dietician (wellness provider
• Pap smear – ages preventative preventative preventative network).
18 and above, programme. programme. programme.
every 24 months. • Preventative • Preventative • Preventative Maternity 100% Scheme tariff. Subject to the 100% Scheme tariff. Subject to the
• HPV dentistry. dentistry. dentistry. Benefits following benefits: following benefits:
vaccinations. • Pap smear – ages • Pap smear – ages • Haemophilus
18 and above, 18 and above, influenzae Type Consultations: Consultations:
every 24 months. every 24 months B vaccine (HIB). • 6 antenatal consultations at a FP OR • 9 antenatal consultations at a FP OR
• HPV • HPV • Mammogram.– gynaecologist OR midwife. gynaecologist OR midwife.
vaccinations. vaccinations.. ages 40 and Ultrasounds: • 1 post-natal consultation at a FP OR
• Mammogram • Mammogram above, every 24 • 1 x 2D ultrasound scan at 1st trimester gynaecologist OR midwife.
– ages 40 and – ages 40 and months. (between 10 to 12 weeks) at a FP OR Ultrasounds:
above, every 24 above, every 24 • HPV gynaecologist OR radiologist. • 1 x 2D ultrasound scan at 1st trimester
months. months. vaccinations. • 1 x 2D ultrasound scan at 2nd trimester (between 10 to 12 weeks) at a FP OR
• PSA Screening • PSA Screening • PSA Screening (between 20 to 24 weeks) at a FP OR gynaecologist OR radiologist.
– ages 50 years – ages 50 years – ages 50 years gynaecologist OR radiologist. • 1 x 2D ultrasound scan at 2nd trimester
and above, every and above, every and above, every (between 20 to 24 weeks) at a FP OR
24 months 24 months 24 months. gynaecologist OR radiologist.
• Pap smear – ages Supplements:
18 and above, • Antenatal iron supplements - 9 fills
every 24 months subject to formulary.
• Antenatal folic acid – 9 fills subject to
formulary.
Disclaimer on exclusions: General and option-specific exclusions apply. Please refer to www.bestmed.co.za for more details.
10 COMPARATIVE GUIDE 2020Contributions
BEAT1 BEAT2 BEAT3 BEAT4
Non-Network (NN) / NN N NN N NN N NN
Network (N)
Medical Savings Account N/A 16% 16% 14%
Principal Risk R1 617 R1 454 R1 660 R1 494 R2 518 R2 266 R4 029
PACE
Member
Savings R0 R0 R316 R284 R479 R431 R656
Total R1 617 R1 454 R1 976 R1 778 R2 997 R2 697 R4 685
Adult Risk R1 255 R1 130 R1 289 R1 160 R1 789 R1 611 R3 328
Dependant
Savings R0 R0 R245 R221 R341 R307 R541
Total R1 255 R1 130 R1 534 R1 381 R2 130 R1 918 R3 869
Child Risk R680 R612 R699 R628 R972 R876 R996
Dependant
Savings R0 R0 R133 R120 R185 R167 R162
Total R680 R612 R832 R748 R1 157 R1 043 R1 158
Maximum contribution
4
child dependants*
Recognition of a child Under 21, unless a registered student.
dependant
* You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.
ABBREVIATIONS
CDL = Chronic Disease List; DBC = Documentation Based Care (back rehabilitation programme); DSP = Designated
Service Provider; FP = Family Practitioner or Doctor; TEMPO = Biometric Screenings; HIB = Haemophilus influenzae
Type B vaccine; HPV = Human Papilloma Virus; M = Member; M1+ = Member and family; MRP = Mediscor Reference
Price; PMB = Prescribed Minimum Benefit; PPN = Preferred Provider Negotiator; PSA = Prostate Specific Antigen.
Did you know that
Chat to us Bestmed’s Pace
directly option range does
using our Chat not have co-payment
Now service on or automatic self-
the Bestmed payment gaps?
website.
COMPARATIVE GUIDE 2020 11The Pace range offers more comprehensive in-hospital and out-of-hospital benefits. These options all have
additional savings accounts to cover extensive out-of-hospital expenses. This range is ideal for families and those PACE1 PACE2 PACE3 PACE4
seeking comprehensive cover. Major medical 100% Scheme 100% Scheme tariff.
maxillofacial tariff. Limited to
surgery strictly R12 440 per
Method of Scheme benefit payment related to certain family.
conditions
PACE1 PACE2 PACE3 PACE4 Dental and oral Limited to Limited to Limited to Limited to
• In-hospital benefits are paid from Scheme risk benefit. Some • In-hospital benefits, out-of-hospital surgery R7 690 per family. R12 780 per family. R16 059 per family. R19 225 per family.
out-of-hospital benefits are paid from the annual savings first benefits and preventative care Prosthesis 100% Scheme 100% Scheme 100% Scheme tariff. 100% Scheme
and once depleted will be paid from the day-to-day benefit. benefits are paid from Scheme risk. (subject to tariff. Limited to tariff. Limited to Limited to tariff. Limited to
• Once the day-to-day benefit is depleted, benefits can be paid • Once out-of-hospital risk benefits are preferred provider, R85 948 per R110 376 per R110 942 per R128 018 per
from the available vested savings. Some preventative care depleted, further claims will be paid otherwise limits family. family. family. family.
benefits are available from Scheme risk benefit. from savings. and co-payments
apply)
• 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). Prosthesis – Sub-limits per Sub-limits per Sub-limits per Sub-limits per
Internal beneficiary: beneficiary: beneficiary: beneficiary:
• *Functional • *Functional • *Functional • *Functional
Note: Sub-limit limited to limited to limited to limited to
subject to the R15 437. R16 794. R18 094. R18 773.
In-hospital benefits above prosthesis
limit.
• Vascular • Vascular • Vascular • Vascular
R31 325. R41 391. R41 505. R47 498.
Note: All benefits mentioned below are subject to pre-authorisation and clinical protocols. *Functional: • Pacemaker • Pacemaker • Pacemaker • Pacemaker
Items utilised (dual chamber) (dual chamber) (dual chamber) (dual chamber)
Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs, this will not
towards treating or R53 492. R59 655. R59 655. R59 655.
affect your savings.
supporting a bodily • Endovascular • Spinal including • Spinal including • Spinal including
function and catheter- artificial disc artificial disc artificial disc
PACE1 PACE2 PACE3 PACE4 based procedures R55 335. R55 440. R64 014.
– no benefit. • Drug-eluting • Drug-eluting • Drug-eluting
Accommodation 100% Scheme tariff. • Spinal R31 325. stents R18 094. stents R18 094. stents R21 318.
(hospital stay) and • Artificial disk – • Mesh R18 094. • Mesh R18 094. • Mesh R18 773.
theatre fees no benefit. • Gynaecology/ • Gynaecology/ • Gynaecology/
Take-home 100% Scheme tariff. Medicine limited to 7 days. • Drug-eluting Urology Urology Urology
medicine stents – PMBs R13 514. R13 571. R15 494.
and DSP • Lens implants • Lens implants • Lens implants
Treatment in 100% Scheme tariff. Limited to 21 days per beneficiary. products only R11 604 R11 604 R17 156
mental health
• Mesh R11 761. per lens per eye. per lens per eye. per lens per eye.
clinics
• Gynaecology/ • Joint • Joint replacements: • Joint
Treatment of 100% Scheme tariff. Urology R8 482. replacements: - Hip replacement replacements:
chemical and Limited to 21 days or R30 760 per beneficiary. Subject to network facilities. • Lens implants - Hip replacement and other major - Hip replacement
substance abuse R6 447 per lens and other major joints R49 760. and other major
per eye. joints R49 703. - Knee replacement joints R57 280.
Consultations and 100% Scheme tariff.
procedures - Knee replacement R57 959. - Knee replacement
R57 676. - Minor joints R66 328.
Surgical 100% Scheme tariff. - Minor joints R21 430. - Minor joints
procedures and R21 430. R21 318.
anaesthetics
Prosthesis – Limited to Limited to Limited to Limited to
Organ transplants 100% Scheme 100% Scheme tariff. External R21 827 R26 011 R26 124 R29 517
tariff. (Only PMBs) per family. per family. per family. per family.
12 COMPARATIVE GUIDE 2020PACE1 PACE2 PACE3 PACE4 Out-of-hospital benefits
Exclusions Joint replacement Not applicable. Note: Benefits below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service
(Prosthesis surgery (except for providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP).
sub-limit subject to PMBs).
preferred provider, PMBs subject to Approved PMB’s will be paid from scheme risk.
otherwise limits prosthesis limits:
and co-payments • Hip replacement
apply) PACE1 PACE2 PACE3 PACE4
and other major
joints R31 891. Overall day-to-day M = R10 382, M = R14 656, M = R18 321, M = R34 153,
• Knee limit M1+ = R20 763. M1+ = R29 313. M1+ = R37 863. M1+ = R55 075.
replacement
FP and specialist Savings first. Savings first. Savings first. Limited to
R42 409.
consultations Limited to Limited to Limited to M = R5 372,
• Minor joints M = R2 138, M = R4 185, M = R4 185, M1+ = R8 708.
R13 175. M1+ = R4 297. M1+ = R8 482. M1+ = R8 482. (Subject to overall
(Subject to overall (Subject to overall (Subject to overall day-to-day limit)
Orthopaedic and 100% Scheme tariff.
day-to-day limit) day-to-day limit) day-to-day limit)
medical appliances
Pathology 100% Scheme tariff.
Diabetes primary 100% of Scheme tariff subject to registration with HaloCare.
Basic radiology 100% Scheme tariff. care consultation 2 primary care consultations at Dis-Chem Pharmacies limited to R341.90 per
consultation. Paid first from the “FP and specialist consultations” day-to-day benefit,
Specialised 100% Scheme tariff. thereafter Scheme risk.
diagnostic imaging
Basic and specialised Savings first. Savings first. Savings first. Limited to
Oncology PMBs only at DSPs. Oncology programme. 100% Scheme tariff. dentistry Basic: Basic: Basic: M = R11 861,
Preventative Preventative Preventative M1+ = R20 020.
Mammary surgery No benefit. 100% Scheme tariff. Limited to R35 000. benefit or savings benefit or savings benefit or savings (Subject to overall
(Breast cancer Subject to pre-authorisation for symmetrising surgery on account. Limit once account. Limit once account. Limit once day-to-day limit)
patient) unaffected breast. savings exceeded. savings exceeded. savings exceeded. Orthodontic:
Specialised: Specialised: Specialised: Subject to pre-
Peritoneal dialysis PMBs only at DSPs. 100% Scheme tariff. Savings account Savings account Savings account authorisation.
and haemodialysis then limit. then limit. then limit.
HIV / AIDS 100% Scheme tariff. Subject to pre-authorisation and DSPs. Orthodontic: Orthodontic: Orthodontic:
Subject to Subject to Subject to
Confinements 100% Scheme tariff. pre-authorisation. pre-authorisation. pre-authorisation.
(Birthing) Limited to Limited to Limited to
M = R3 934, M = R6 596, M = R7 107,
Refractive surgery 100% Scheme 100% Scheme 100% Scheme tariff. M1+ = R7 985. M1+ = R13 192. M1+ = R13 250.
and all types tariff. Limited to tariff. Limited to Limited to R9 613 per eye. (Subject to overall (Subject to overall (Subject to overall
of procedures R8 550 per eye. R8 934 per eye. day-to-day limit) day-to-day limit) day-to-day limit)
to improve or
stabilise vision
(except cataracts) Medical aids, Savings first. Savings first. Savings first. 100% Scheme
apparatus and 100% Scheme 100% Scheme 100% Scheme tariff. Limited to
Midwife-assisted 100% Scheme tariff.
appliances including tariff. Limited tariff. Limited to tariff. Limited to R9 952 per family.
births
wheelchairs and to R10 970 per R9 952 per family. R9 952 per family. (Subject to overall
Supplementary 100% Scheme tariff. hearing aids family. (Subject to (Subject to overall (Subject to overall day-to-day limit).
services overall day-to-day day-to-day limit). day-to-day limit). Limit on
Hearing aids are limit) Limit on Limit on wheelchairs of
Alternatives to 100% Scheme tariff. subject to pre- wheelchairs of wheelchairs of R13 458 per family
hospitalisation authorisation. Hearing aids can R13 458 per family R13 458 per family per 48 months.
be claimed every per 48 months. per 48 months. Limit on hearing
Emergency Services rendered by ER24. 24 months. Limit on hearing Limit on hearing aids of R34 379
evacuation aids of R27 425 aids of R30 874 per beneficiary per
International travel Up to R10 million and a maximum of 90 days. Services rendered by Bryte Insurance and per beneficiary per per beneficiary per 24 months.
cover managed by ER24. 24 months. 24 months.
COMPARATIVE GUIDE 2020 13PACE1 PACE2 PACE3 PACE4 PACE1 PACE2 PACE3 PACE4
Insulin pump No benefit. 100% Scheme Oncology PMBs only at DSPs. Oncology programme. 100% Scheme tariff.
(excluding tariff.
consumables) Peritoneal dialysis PMBs only at DSPs. 100% Scheme tariff.
Limited to and haemodialysis
R40 000 per
beneficiary every
24 months.
Subject to pre- Medicine
authorisation.
Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers, designated
Supplementary Savings first. Savings first. Savings first. Limited to
service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP). Refer to the Chronic
services Limited to Limited to Limited to M = R5 372,
M = R4 195, M = R5 260, M = R2 566, M1+ = R10 574. Conditions List at the back of the Comparative Guide.
M1+ = R8 708. M1+ = R10 574. M1+ = R5 372. (Subject to overall Note: Approved CDL, PMB and non-CDL chronic medicine costs will be paid from the non-CDL chronic medicine limit
(Subject to overall (Subject to overall (Subject to overall day-to-day limit) first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
day-to-day limit) day-to-day limit) day-to-day limit)
Note: Approved PMB biological and Non-PMB biological medicine costs will be paid from the Biological limit first.
Wound care benefit Savings first. Savings first. Savings first. Limited to Once the limit is depleted, only PMB biological medicine costs will continue to be paid unlimited from Scheme risk.
(incl. dressings, 100% Scheme 100% Scheme 100% Scheme R13 118 per
negative pressure tariff. Limited to tariff. Limited to tariff. Limited to family. (Subject to
wound therapy R3 450 per family. R6 559 per family. R10 178 per overall day-to-day PACE1 PACE2 PACE3 PACE4
-NWPT- treatment (Subject to overall (Subject to overall family. (Subject to limit) CDL & PMB chronic 100% Scheme 100% Scheme 100% Scheme 100% Scheme
and related nursing day-to-day limit) day-to-day limit) overall day-to-day medicine tariff. Co-payment tariff. Co-payment tariff. Co-payment tariff. Co-payment
services – limit) of 35% for of 30% for of 25% for of 20% for
out-of-hospital) non-formulary non-formulary non-formulary non-formulary
Optometry benefit Benefits available every 24 months from date of service. medicine. medicine. medicine. medicine.
(PPN capitation Non-CDL chronic 7 conditions. 18 conditions. 19 conditions. 28 conditions.
provider) Network Provider (PPN) medicine 90% Scheme tariff. 90% Scheme tariff. 90% Scheme tariff. 90% Scheme tariff.
Consultation - 1 per beneficiary. Limited to Limited to Limited to Limited to
Frame = R868 covered AND M = R6 333, M = R8 708, M = R14 046, M = R18 942,
100% of cost of standard lenses (single vision OR bifocal OR multifocal) OR Contact M1+ = R12 666. M1+ = R17 416. M1+ = R28 092. M1+ = R38 055.
lenses = R1 510 Co-payment Co-payment Co-payment Co-payment
OR of 30% for of 25% for of 20% for of 15% for
Non-network Provider non-formulary non-formulary non-formulary non-formulary
Consultation - R316 fee at non-network provider Frame = R579 AND medicine. medicine. medicine. medicine.
Single vision lenses = R184 OR
Bifocal lenses = R431 OR Biologicals and other PMBs only - Limited to Limited to Limited to
Multifocal lenses = R747 OR high-cost medicine subject to pre- R158 221 R316 652 R468 645
Contact lenses = R1 510 approval. per beneficiary. per beneficiary. per beneficiary.
Basic radiology Savings first. Savings first. Savings first. 100% Scheme Acute medicine Savings first. Savings first. Savings first. Limited to
and pathology 100% Scheme 100% Scheme 100% Scheme tariff. Limited to Limited to Limited to Limited to M = R8 482,
tariff. Limited to tariff. Limited to tariff. Limited to M = R5 372, M = R2 240, M = R4 637, M = R1 471, M1+ = R13 175.
M = R3 110, M = R3 110, M = R3 393, M1+ = R10 574. M1+ = R4 637. M1+ = R9 273. M1+ = R3 619. (10% co-payment)
M1+ = R6 220. M1+ = R6 220. M1+ = R6 729. (Subject to overall (Subject to overall (Subject to overall (Subject to overall (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). day-to-day limit).
day-to-day limit) day-to-day limit) day-to-day limit)
Over-the-counter *Member choice: 1. R650 OTC limit OR 2. Access to full savings Savings account.
Specialised 100% Scheme MRI/CT scans: Maximum of 3 scans per beneficiary. (OTC) medicine for OTC purchases (after R650 limit) = self-payment gap
diagnostic imaging tariff. Limited PET scan: 1 scan per beneficiary. 100% Scheme tariff. accumulation. Subject to available savings.
to R13 911 per Includes sunscreen,
family. vitamins and minerals
with nappi codes on
Rehabilitation Vested savings. 100% Scheme tariff. Scheme formulary
services after trauma
HIV / AIDS 100% Scheme tariff. Subject to pre-authorisation and DSPs. *The Default OTC choice is 1. R650 OTC limit. Members wishing to choose the other option are welcome to contact Bestmed
14 COMPARATIVE GUIDE 2020Preventative care benefits PACE1 PACE2 PACE3 PACE4
Maternity 100% Scheme tariff. Subject to the following benefits:
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers,
Benefits
designated service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP).
Consultations:
PACE1 PACE2 PACE3 PACE4 • 9 antenatal consultations at a FP OR gynaecologist OR midwife.
• 1 post-natal consultation at a FP OR gynaecologist OR midwife.
Preventative care • Flu vaccines. • Flu vaccines. Ultrasounds:
• Pneumonia • Pneumonia vaccines. • 1 x 2D ultrasound scan at 1st trimester (between 10 to 12 weeks) at a FP OR
Note: Refer to vaccines. • Paediatric immunisations. gynaecologist OR radiologist.
Scheme rules for • Paediatric • Female contraceptives – R2 205 per beneficiary per year. • 1 x 2D ultrasound scan at 2nd trimester (between 20 to 24 weeks) at a FP OR
funding criteria
immunisations. • Back and neck preventative programme. gynaecologist OR radiologist.
applicable to each
• Female • Preventative dentistry. Supplements:
preventative
care benefit. contraceptives – • Haemophilus influenzae Type B vaccine. (HIB). • Antenatal iron supplements - 9 fills subject to formulary.
R2 205 per • Mammogram. • Antenatal folic acid – 9 fills subject to formulary.
beneficiary per • PSA screening – ages 50 and above, every 24 months.
year. • HPV vaccinations. Disclaimer on exclusions: General and option-specific exclusions apply.
• Back and neck • Bone densitometry. Please refer to www.bestmed.co.za for more details.
preventative • Pap smear – ages 18 and above, every 24 months.
programme.
• Preventative Contributions
dentistry.
• Haemophilus PACE1 PACE2 PACE3 PACE4
influenzae Type B
vaccine. (HIB). Medical Savings Account 19% 14% 14% 3%
• Mammogram. Principal Member Risk R3 183 R4 786 R5 495 R7 743
• HPV vaccinations.
• Pap smear – age Savings R747 R780 R895 R240
18 and above,
Total R3 930 R5 566 R6 390 R7 983
every 24 months.
• PSA screening Adult Dependant Risk R2 236 R4 694 R4 424 R7 743
– ages 50 and
Savings R524 R764 R720 R240
above, every 24
months. Total R2 760 R5 458 R5 144 R7 983
Tempo Individual Health Risk Assessments (Adults aged 18 and older) – Biometric screening Child Dependant Risk R804 R1 055 R945 R1 813
Programme and lifestyle questionnaire to be completed at a network pharmacy or onsite at selected
(Wellness) Savings R188 R172 R154 R57
employers (1 per year).
Child dependant assessments Total R992 R1 227 R1 099 R1 870
Note: Completing
• Ages 13-17 years: Assessment done by a contracted biokineticist (wellness network
your Health Risk Maximum contribution 4
provider) – 1 per beneficiary per year.
Assessment child dependant*
(HRA) unlocks • Ages 3-12 years: Assessment done by a contracted occupational therapist (wellness
the other Tempo network provider) – 1 per beneficiary per year. Recognition of a child dependant Under 21, unless a registered student.
benefits. • Ages 0-2 years: Baby growth and development assessments done at a contracted
pharmacy clinic – 3 assessments per year.
*You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.
One parent • Family assessments - Nutrition
must complete • Family nutritional assessment done at a contracted dietician (wellness network provider) – ABBREVIATIONS
their HRA in 1 per family per year. DBC = Documentation Based Care (Back Rehabilitation Programme); DSP = Designated Service Provider; FP = Family
order to unlock Practitioner or Doctor; TEMPO = Biometric Screenings; HIB = Haemophilus influenzae Type B vaccine; HPV = Human
• Fitness and nutritional interventions (beneficiaries 18 and older)
assessments
• 3 individualised consultations per year at a contracted biokineticist (wellness provider Papilloma Virus; M = Member; M1+ = Member and family; MRI/CT scans = Magnetic Resonance Imaging/Computed
for beneficiaries
younger than 18. network). Tomography scans; MRP = Mediscor Reference Price; NP = Network Provider; PET scan = Positron Emission
• 3 individualised consultations per year at a contracted dietician (wellness provider Tomography scan; PMB = Prescribed Minimum Benefits; PPN = Preferred Provider Negotiators; PSA = Prostate
network). Specific Antigen.The Pulse range is ideally suitable for you if:
• 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.
• You are looking for unlimited comprehensive cover for hospitalisation and the added benefit of preventative care.
Method of Scheme benefit payment
PULSE1 PULSE2
PULSE • In-hospital benefits are paid from Scheme risk.
• Some preventative care benefits are available from
• In-hospital benefits are paid from Scheme risk.
• Some day-to-day benefits and preventative care
Scheme risk. benefits are available from Scheme risk.
• Some out-of-hospital benefits are paid from • Some out-of-hospital benefits are paid from
Scheme risk. Scheme risk.
• Only Pulse specialist DSP network. • Only Pulse specialist DSP network.
• Benefits relating to conditions that meet the criteria for PMBs will be covered in full when using DSPs.
In-hospital benefits
All benefits below are subject to pre-authorisations and clinical protocols and designated hospital networks.
PULSE1 PULSE2
Accommodation (hospital stay) 100% Scheme tariff at a DSP hospital.
and theatre fees
Take-home medicine 100% Scheme tariff. 100% Scheme tariff.
Medicine limited to 3 days. Medicine limited to 7 days.
Treatment in mental health 100% Scheme tariff. Limited to 21 days per beneficiary.
clinics
Treatment of chemical and 100% Scheme tariff (only PMBs). 100% Scheme tariff. Limited to 21
substance abuse Limited to 21 days per beneficiary. days or R30 760 per beneficiary.
Subject to network facilities. Subject to network facilities.
Consultations and procedures 100% Scheme tariff.
Unlimited FP Surgical procedures and
anaesthetics
100% Scheme tariff. Excluded
from benefits: functional nasal
100% Scheme tariff.
surgery, surgery for medical
consultations conditions e.g. Epilepsy,
Parkinson’s disease and
on our Pulse procedures where stimulators
are used.
Network! Organ transplants 100% Scheme tariff (only PMBs).
Major medical maxillofacial No benefit. 100% Scheme tariff.
surgery strictly related to certain
conditions
Dental and oral surgery No benefit. 100% Scheme tariff.
16 COMPARATIVE GUIDE 2020PULSE1 PULSE2 PULSE1 PULSE2
Prosthesis (subject to preferred 100% Scheme tariff. 100% Scheme tariff. Midwife-assisted births 100% Scheme tariff.
provider, otherwise limits and Limited to R50 552 per family. Limited to R101 216 per family.
co-payments apply) Supplementary services 100% Scheme tariff.
Prosthesis – Internal Sub-limits per beneficiary: Sub-limits per beneficiary: HIV / AIDS PMBs only at DSPs 100% Scheme tariff. Subject to
• *Functional R10 744. • *Functional R16 794. pre-authorisation and DSPs.
Note: Sub-limit subject to the • Vascular R25 049. • Vascular R39 129. Alternatives to hospitalisation 100% Scheme tariff.
above prosthesis limit • Pacemaker (dual chamber) • Pacemaker (dual chamber)
R40 939. R53 040. Emergency evacuation Services rendered by ER24
*Functional: Items utilised
• Endovascular and catheter-based • Spinal R39 129. International travel cover Up to R10 million and a maximum of 90 days. Services rendered by Bryte
towards treating or supporting
a bodily function procedures – no benefit. • Artificial disk R17 190. Insurance and managed by ER24.
• Spinal R25 049. • Drug-eluting stents R17 190.
• Artificial disk – no benefit. • Mesh R17 190. Co-payments Co-payment where procedure has Co-payment of up to R11 309
been clinically approved: per event for voluntary use of a
• Drug-eluting stents – PMBs and • Gynaecology/Urology R12 780.
• R3 619 on all laparoscopic non-DSP hospital.
DSP products only. • Lens implants R10 970 per lens
procedures,
• Mesh R9 161. per eye.
• R3 619 on prostate procedures,
• Gynaecology/Urology R7 566. • Joint replacements:
• R3 619 on procedures for
• Lens implants R5 260 per lens - Hip replacement and other major
prolapse/incontinence,
per eye. joints R46 819.
• R3 619 on arthroscopy other
- Knee replacement R54 679.
than acute trauma,
- Minor joints R20 356.
• R3 619 on endoscopy
Prosthesis – External No benefit (PMBs only). Limited to R24 427 per family. investigations done primarily in
hospital
Exclusions (Prosthesis sub-limit Joint replacement surgery (except Not applicable.
• Co-payment of up to R11 309
subject to preferred provider, for PMBs).
otherwise limits and PMBs subject to prosthesis per event for voluntary use of
co-payments apply) limits: a non-DSP hospital.
• Hip replacement and other major
joints R25 672.
• Knee replacement R32 457. Out-of-hospital benefits
• Minor joints R12 157.
Note: Granting of benefits under the primary care services and the Scheme benefits shall be subject to treatment
Orthopaedic and medical 100% Scheme tariff. 100% Scheme tariff.
protocols, preferred providers, DSPs, dental procedure codes, pathology and radiology lists of codes and medicine
appliances Limited to R6 220 per family.
formularies as accepted by the Scheme.
Basic radiology and pathology 100% Scheme tariff.
Specialised diagnostic imaging 100% Scheme tariff. Subject to pre-authorisation. PULSE1 PULSE2
Oncology PMBs only at DSPs. Oncology programme. 100% Overall day-to-day limit N/A M = R13 854, M1+ = R27 537.
Scheme tariff. FP consultations Unlimited FP visits. Subject to Unlimited FP visits at Bestmed FP
Peritoneal dialysis and PMBs only at DSPs. 100% Scheme tariff. Only at DSPs. Bestmed Pulse1 FP networks. network providers.
haemodialysis
Diabetes primary care 100% of Scheme tariff subject to registration with HaloCare.
Confinements (Birthing) 100% Scheme tariff. consultation 2 primary care consultations at Dis-Chem Pharmacies limited to
R341.90 per consultation.
Mammary surgery No benefit. 100% Scheme tariff. Limited
(Breast cancer patients) to R35 000 subject to pre-
authorisation for symmetrising Pulse2 option: Paid first from the day-to-day benefit, thereafter Scheme
surgery on unaffected breast.. risk.
Refractive surgery and all types No benefit (PMBs only). 100% Scheme tariff. Limited to Casualty and out-of-network FP Limited to R1 357 per family per Limited to R1 471 per family per
of procedures to improve or R8 990 per eye. visits year. year.
stabilise vision (except cataracts)
COMPARATIVE GUIDE 2020 17PULSE1 PULSE2 PULSE1 PULSE2
Specialist consultations Specialist consultations must Specialist consultations must be Basic radiology and Subject to Provider Network. Subject to NP protocols and tariff
be referred by a Pulse1 Network referred by Network Provider. pathology Pulse1 Protocols and tariff lists lists. (Subject to overall day-to-
Provider. Limited to M = R1 131, Limited to M = R3 054, M1+ = R5 apply. Referral by Pulse1 Network day limit). Referral by NP required.
M1+ = R 1 697. 881. Provider required. Subject to pre-authorisation.
Subject to Pulse Specialist DSP Subject to overall day-to-day limit.
network. R500 penalty for non- Subject to Pulse specialist DSP Specialised diagnostic imaging No benefit. Subject to pre-authorisation.
referral to specialists in PMB network. MRI/CT scans: A maximum of
cases. 3 scans per beneficiary.
PET scans: 1 scan per beneficiary.
Basic and specialised dentistry Basic dentistry: Subject to Specialised dentistry is subject to
Bestmed Pulse Dental Network. pre-authorisation. HIV / AIDS PMBs only at DSPs. 100% Scheme tariff. Subject to
Specialised dentistry: No benefit. Limited to pre-authorisation and DSPs.
M = R6 955,
Peritoneal dialysis and PMBs only at DSPs. 100% Scheme tariff. Only at DSPs.
M1+ = R8 821
haemodialysis
Subject to overall day-to-day limit.
Oncology PMBs only at DSPs. Oncology programme. 100%
Medical aids, apparatus and No benefit. Limited to R9 839 per family. Limit
Scheme tariff.
appliances including wheelchairs on wheelchairs of R12 666 per
and hearing aids family, per 48 months. Rehabilitation services after No benefit.
Limit on hearing aids of R27 368 trauma
per beneficiary per 24 months
subject to pre-authorisation,
quotation, audiogram and
motivation).
Medicine
Supplementary services No benefit. Limited to
M = R4 071, Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers, designated
M1+ = R8 086. service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP). Refer to the Chronic
(Subject to overall day-to-day Conditions List at the back of the Comparative Guide.
limit)
Note: Approved CDL, PMB and non-CDL chronic medicine costs will be paid from the non-CDL chronic medicine limit
Wound care benefit (incl. No benefit. Limited to R9 500 per family. first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
dressings, negative pressure
wound therapy treatment Note: Approved PMB biological and Non-PMB biological medicine costs will be paid from the Biological limit first.
-NWPT- and related nursing Once the limit is depleted, only PMB biological medicine costs will continue to be paid unlimited from Scheme risk.
services – out-of-hospital)
Optometry benefit Benefits available every 24 Benefits available every 24 PULSE1 PULSE2
(PPN capitation provider) months from date of service at months from date of service.
CDL & PMB chronic medicine 100% Scheme tariff. 100% Scheme tariff.
PPN provider only.
40% co-payment on 25% co-payment on
Network Provider (PPN)
Consultation - only PPN providers. non-formulary medicine. non-formulary medicine.
Consultation - 1 per beneficiary.
Frame = R237 covered AND Frame = R868 covered AND Non-CDL chronic medicine No benefit. 16 conditions.
100% of cost of standard lenses 100% of cost of standard lenses 90% Scheme tariff.
(single vision OR bifocal OR (single vision OR bifocal OR Limited to M = R6 559,
multifocal) OR multifocal) OR Contact lenses = M1+ = R13 118.
Contact lenses = R600 R1 510 Co-payment of 20% for
OR non-formulary medicine.
Non-network Provider
Consultation - R316 fee at non- Biologicals and other high-cost PMBs only - subject to Limited to R149 279 per
network provider Frame = R579 medicine pre-approval. beneficiary.
AND
Single vision lenses = R184 OR Acute medicine 100% Scheme tariff. 100% Scheme tariff.
Bifocal lenses = R431 OR Subject to Bestmed formulary. Limited to M = R4 354,
Multifocal lenses = R747 OR M1+ = R8 821. (Subject to overall
Contact lenses = R1 510 day-to-day limit)
18 COMPARATIVE GUIDE 2020PULSE1 PULSE2 PULSE1 PULSE2
Over-the-counter (OTC) medicine Limited to R368 per family. Limited to R579 per family. Maternity Benefits 100% Scheme tariff. Subject to the following benefits:
Includes sunscreen, vitamins and Consultations:
minerals with nappi codes on • 9 antenatal consultations at a FP OR gynaecologist OR midwife.
Scheme formulary • 1 post-natal consultation at a FP OR gynaecologist OR midwife.
Ultrasounds:
• 1 x 2D ultrasound scan at 1st trimester (between 10 to 12 weeks) at a
Preventative care benefits FP OR gynaecologist OR radiologist.
• 1 x 2D ultrasound scan at 2nd trimester (between 20 to 24 weeks) at a
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers, FP OR gynaecologist OR radiologist.
designated service providers, formularies, funding guidelines and the Mediscor Reference Price (MRP). Supplements:
• Antenatal iron supplements - 9 fills subject to formulary.
• Antenatal folic acid – 9 fills subject to formulary.
PULSE1 PULSE2
Disclaimer on exclusions: General and option specific exclusions apply. Please refer to www.bestmed.co.za for more details.
Preventative care • Flu vaccines.
• Pneumonia vaccines.
Note: Refer to Scheme rules for • Paediatric immunisations.
funding criteria applicable to • Back and neck preventative programme. Contributions
each preventative care benefit.
• Female contraceptives R2 205 per beneficiary per year.
• HPV vaccinations (Females 9-26 years) PULSE1 PULSE2
Tempo Programme (Wellness) Individual Health Risk Assessments (Adults aged 18 and older) – Income level R0 – R5 500 p.m. R5 501 – R8 500 p.m. > R8 501 p.m. N/A
Biometric screening and lifestyle questionnaire to be completed at a Medical Savings Account N/A N/A
Note: Completing your Health network pharmacy or onsite at selected employers (1 per year).
Risk Assessment (HRA) unlocks Child dependant assessments Principal Risk R1 626 R1 953 R2 344 R5 770
the other Tempo benefits. Member
• Ages 13-17 years: Assessment done by a contracted biokineticist
Savings R0 R0 R0 R0
(wellness network provider) – 1 per beneficiary per year.
One parent must complete
their HRA in order to unlock • Ages 3-12 years: Assessment done by a contracted occupational Total R1 626 R1 953 R2 344 R5 770
assessments for beneficiaries therapist (wellness network provider) – 1 per beneficiary per year.
Adult Risk R1 545 R1 856 R2 109 R5 770
younger than 18 • Ages 0-2 years: Baby growth and development assessments done at a
Dependant
contracted pharmacy clinic – 3 assessments per year. Savings R0 R0 R0 R0
• Family assessments - Nutrition
Total R1 545 R1 856 R2 109 R5 770
• Family nutritional assessment done at a contracted dietician (wellness
network provider) – 1 per family per year. Child Risk R978 R1 172 R1 172 R1 371
• Fitness and nutritional interventions (beneficiaries 18 and older) Dependant
• 3 individualised consultations per year at a contracted biokineticist Savings R0 R0 R0 R0
(wellness provider network). Total R978 R1 172 R1 172 R1 371
• 3 individualised consultations per year at a contracted dietician (wellness
provider network). Maximum contribution child Not applicable. 4
dependant*
Recognition of a child Not applicable. Under 21, unless a registered
dependant student.
*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.
ABBREVIATIONS
DBC = Documentation Based Care (Back Rehabilitation Programme); DSP = Designated Service Provider; FP =
Family Practitioner or Doctor; TEMPO= Biometric Screenings; 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; PSA = Prostate
Specific Antigen.
COMPARATIVE GUIDE 2020 19You can also read
