2016 Bestmed Comparative Guide

Transcription

Comparative
Guide
2016
Better living. Better life.
About
Bestmed
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.
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Bestmed 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.
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Below is a summary of the current Bestmed Provider networks:
Family practitioners
Specialists
Pathology
Oncology
Healthcare Provider Networks
Pharmacies
Dentists
Dental therapists
Dental technicians
Orthodontists
Audiologists and speech therapists
Physiotherapists
Occupational therapists
Hearing aid acousticians
Ancillary Networks
Counsellors
Midwives
Psychologists
Biokineticists
Dieticians
Stents and pacemakers
Orthopaedic prosthesis
Product Supply Networks
Oxygen supply
Sleep apnoea devices
Hearing aid devices
Drug and alcohol rehabilitation
Emergency services
Service Networks
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.
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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].
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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 optionspecific 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.
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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. Prostatespecific 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.
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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.
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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.
Beat
Method of Scheme benefit payment
Beat1
Beat2
Beat3
Beat4
In-hospital services are paid from
Scheme risk benefit and out-ofhospital services will be for the
member’s own account. Some
preventative care services are
available from Scheme risk benefit.
Scheme risk benefit and out-ofhospital services will be paid from the
savings account. Some preventative
care services are available from
Scheme risk benefit.
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.
Scheme risk benefit. Some outof-hospital services are paid from
the annual savings first and, once
depleted, will be paid from the
day-to-day benefit. Once the dayto-day benefit is depleted, services
can be paid from the available vested
savings. Some preventative care
services are available from Scheme
risk benefit.
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.
In-hospital benefits
Note: Benefits mentioned below are subject to pre-authorisation and clinical protocols.
Beat1
Accommodation (hospital stay)
and theatre fees
Beat2
100% Scheme tariff.
DSP specialist network applicable if the discounted network option is chosen.
Take-home medicine
100% Scheme tariff.
Limited to 21 days or R24 000 per beneficiary. Subject to network facilities.
100% Scheme tariff.
DSP specialist network applicable if the discounted network option is chosen.
Surgical procedures and anaesthetics
100% Scheme tariff. (Only PMBs).
100% Scheme tariff.
Limited to R9 600
per family.
Dental and oral surgery
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.
100% Scheme tariff.
100% Scheme tariff.
Organ transplants
10
100% Scheme tariff.
100% Scheme tariff. Limited to 21 days per beneficiary.
Treatment of chemical and
substance abuse
Major medical maxillo-facial surgery
strictly related to certain conditions
Beat4
100% Scheme tariff. Limited to 7 days’ medicine.
Treatment in mental health clinics
Consultations and procedures
Beat3
Limited to R5 000 per family.
100% Scheme tariff.
Limited to R6 000
per family.
100% Scheme tariff.
Limited to R9 800
per family.
Limited to R7 500
per family.
The Beat range
offers flexible
hospital benefits
with limited savings
to pay for out-ofhospital expenses on
some options.
In-hospital benefits (continued)
Beat1
Prosthesis (Subject to preferred
provider, otherwise limits and copayments apply)
Sub-limits per beneficiary:
■■
Note: Sub-limit subject to
the above prosthesis limit.
*Functional: Items utilised
towards treating or supporting
a bodily function
■■
■■
■■
■■
■■
■■
■■
■■
■■
Functional limited to
R10 000
Vascular R22 250
Pacemaker (dual
chamber) R30 500
Endovascular no benefit
Spinal R22 250
Beat3
Beat4
100% Scheme tariff. Limited to R59 250 per family.
■■
100% Scheme tariff.
Limited to R72 300
per family.
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
■■
■■
■■
Artificial disk no benefit
■■
Mesh R7 850
■■
Drug-eluting stents no benefit
Gynaecology/Urology R6 500
■■
Lens implants R5 050 per lens
■■
Mesh R7 850
■■
Gynaecology/Urology
R6 400
■■
Lens implants R4 950
per lens
■■
■■
Prosthesis – External
Exclusions (Prosthesis
sub-limit subject to preferred
provider, otherwise limits and
co-payments apply)
Limited to R14 200
per family.
Joint replacement surgery.
(Except for PMBs). PMBs
subject to prosthesis limits:
■■
■■
■■
Hip replacement and
other major joints
R23 500
■■
Knee replacement R29 250
■■
Minor joints R10 000
100% Scheme tariff.
Diagnostic imaging
100% Scheme tariff.
Confinements
Refractive surgery
100% Scheme tariff. Subject to co-payments
Drug-eluting stents
R13 400
Mesh R8 800
Gynaecology/Urology
R6 500
per lens
Joint replacements:
−− Hip replacement and
other major joints
R24 500
−− Knee replacement
R32 550
−− Minor joints R10 000
Not applicable.
100% Scheme tariff.
100% Scheme tariff.
100% Scheme tariff.
Subject to pre-authorisation and protocols. Limited to R6 500 per eye.
Supplementary services
100% Scheme tariff.
Co-payments
Artificial disk no benefit
100% Scheme tariff.
100% Scheme tariff.
Emergency evacuation
Spinal R23 800
Oncology programme. 100% Scheme tariff.
Midwife-assisted births
Alternatives to hospitalisation
Endovascular –
no benefit
Minor joints R9 900
Pathology
Peritoneal dialysis and
haemodialysis
Pacemaker (dual
chamber) R39 900
Knee replacement
R28 950
100% Scheme tariff.
Oncology
Vascular R23 800
Hip replacement and other major joints
R23 690
R23 700
Orthopaedic and medical appliances
Specialised diagnostic imaging
R12 000
Limited to R17 400
per family.
Joint replacement surgery. (Except for PMBs).
PMBs subject to prosthesis limits:
■■
Beat
Prosthesis – Internal
Beat2
100% Scheme tariff.
Limited to R58 600
per family.
100% Scheme tariff.
Subject to pre-authorisation
and protocols. Limited to
R7 000 per eye.
100% Scheme tariff.
100% Scheme tariff. Pre-authorised and rendered by ER24.
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.
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Out-of-hospital benefits
Note: Benefits mentioned below may be subject to pre-authorisation and clinical protocols.
All payments are made at Scheme tariff.
Beat1
Beat
Overall day-to-day limit
Beat2
Beat3
Not applicable.
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.
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)
No benefit.
Savings account.
day-to-day limit)
Wound care benefit (incl.
dressings and negative pressure
wound therapy (NPWT) treatment
and related nursing services out-of-hospital)
Optometry benefit
(PPN capitation provider)
Savings first. 100% Scheme tariff.
Limited to R2 600 per family. (Subject to overall day-to-day limit)
No benefit.
Savings account.
■■
■■
Consultation R325
Frame R550
−− Single-vision lenses
R150 OR
−− Bifocal lenses
R325 OR
−−
■■
Diagnostic imaging
and pathology
No benefit.
day-to-day limit)
■■
■■
■■
Consultation R325
Frame R500
−− Single-vision lenses
R150 OR
−−
Bifocal lenses R325 OR
−−
Multifocal lenses R600
Contact lenses R1 210
day-to-day limit)
100% Scheme tariff.
Limited to R8 350 per
family.
100% Scheme tariff.
Maternity benefits
No benefit.
Rehabilitation services
after trauma
No benefit.
Multifocal lenses R600
Savings account.
100% Scheme tariff.
Oncology
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Beat4
M = R9 900, M1+ = R19 850.
Savings account.
Savings account.
100% Scheme tariff.
2 sonars and up to 12 antenatal consultations.
Vested savings.
Medicine
Note: 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
Beat3
Beat4
100% Scheme tariff. Co-payment of 35% for non-formulary medicine.
Non-CDL chronic medicine
No benefit.
Biologicals and other
high-cost medicine
100% Scheme tariff.
Co-payment of 30% for
non-formulary medicine.
5 conditions.
16 conditions.
85% Scheme tariff. Limited to
M = R2 700, M1+ = R5 450.
85% Scheme tariff. Limited to
M = R7 400, M1+ = R14 750.
Beat
CDL chronic medicine
Beat2
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.
Preventative care benefits
Beat1
Preventative care
Health Check and
lifestyle screenings
Note: Refer to Scheme
rules for funding
criteria applicable to
each preventative
care benefit.
■■
■■
■■
■■
■■
■■
■■
Beat2
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.
■■
■■
■■
■■
■■
Beat3
Flu vaccines
■■
Pneumonia vaccines
■■
■■
DBC programme
Preventative dentistry
(incl. gloves and sterile
equipment)
Health Check
■■
■■
■■
■■
■■
Beat4
Flu vaccines
■■
Flu vaccines
Pneumonia vaccines
■■
Pneumonia vaccines
■■
DBC programme
equipment)
■■
■■
■■
DBC programme
equipment)
Haemophilus influenzae
Type B vaccine (HIB)
Health Check
■■
■■
Mammogram
■■
HPV vaccinations
■■
■■
■■
■■
PSA Screening for ages
50 years and above, every
24 months.
Health Check
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.
13
Chronic conditions list (CDL & non-CDL)
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).
Beat
Beat1
Beat2
Reimbursement for CDL
Reimbursement for non-CDL
CDL 1
85% Scheme tariff
35%
30%
0
5
16
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 13
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 2
Attention 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
14
Beat4
100% Scheme tariff
No benefit
Non-formulary co-payment
No. of non-CDL conditions covered
Beat3
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 15
Pulmonary embolism
non-CDL 16
Female menopause
Contributions
Beat1
ADULT DEPENDANT
CHILD DEPENDANT
Beat3
Beat4
Non-Network (NN)/
Network (N)
NN
N
NN
N
NN
N
NN
R2 688
Risk
R1 144
R1 029
R1 174
R1 057
R1 782
R1 604
Savings
R0
R0
R240
R216
R365
R328
R551
Total
R1 144
R1 029
R1 414
R1 273
R2 147
R1 932
R3 239
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
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.
Beat
PRINCIPAL MEMBER
Beat2
* 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;
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.
15
App-iness. New
and improved.
Here are seven reasons why:
•
•
•
•
•
•
•
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.
So don’t delay, download your new and improved
Bestmed App today.
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
Better living. Better life.
© Bestmed Medical Scheme 2016
Bestmed Medical Scheme is a registered Medical Scheme (reg. no. 1252)
and an Authorised Financial Services Provider (FSP no. 44058).
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.
Pace
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.
Pace1
Pace2
Pace3
Pace4
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.
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.
All benefits below are subject to pre-authorisation and clinical protocols.
Pace1
Pace2
Accommodation (hospital stay) and
theatre fees
Treatment in mental health
clinics
Treatment of chemical and
substance abuse
100% Scheme tariff.
Limited to 21 days or R24 000 per beneficiary. Subject to network facilities.
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
Pace
Pace4
100% Scheme tariff.
Take-home medicine
100% Scheme tariff.
Limited to R9 700
per family.
Prosthesis (Subject to preferred
co-payments apply)
Note: Sub-limit subject to
the above prosthesis limit.
a bodily function
■■
■■
Limited to R10 000
per family.
Limited to R12 500
per family.
Limited to R15 000
per family.
100% Scheme tariff.
Limited to R70 650
per family.
100% Scheme tariff.
Limited to R86 100
per family.
100% Scheme tariff.
Limited to R86 500
per family.
100% Scheme tariff.
Limited to R99 900
per family.
R11 500
Vascular R23 300 Pacemaker (dual
chamber) R39 850
■■
■■
■■
R12 500
Vascular R30 800
Pacemaker (dual
chamber) R44 400
■■
■■
■■
R13 500
Vascular R30 900
Pacemaker (dual
chamber) R44 400
■■
■■
■■
R14 000
Vascular R35 350
Pacemaker (dual chamber)
R44 400
■■
■■
Spinal R30 800
■■
Spinal R30 900
■■
Spinal R35 350
■■
Spinal R23 300
■■
Artificial disk R13 500
■■
■■
■■
■■
Drug-eluting stents no benefit
■■
Mesh R8 750
■■
Gynaecology/Urology
R6 300
■■
per lens
■■
■■
■■
■■
■■
100% Scheme tariff.
Limited to R6 000
per family.
■■
18
Pace3
Drug-eluting stents
R13 500
Mesh R13 500
Gynaecology/Urology
R10 100
per lens
Joint replacements:
other major joints
R37 000
R42 950
■■
■■
■■
■■
■■
Drug-eluting stents
R13 500
Mesh R13 500
Gynaecology/Urology
R10 200
per lens
Joint replacements:
other major joints
R37 100
R43 150
■■
■■
■■
■■
■■
Drug-eluting stents
R15 850
Mesh R14 000
Gynaecology/Urology
R11 550
per lens
Joint replacements:
other major joints
R42 650
R49 350
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, lowfat milk or yoghurt, wholewheat
toast and a boiled egg.
Pace
Exclusions (Prosthesis
sub-limit subject to preferred
co-payments apply)
Pace1
Pace2
Pace3
Pace4
Limited to R17 100
per family.
Limited to R20 290
per family.
Limited to R20 400
per family.
Limited to R23 050
per family.
Not applicable.
Joint replacement surgery
(except for PMBs). PMBs
subject to prosthesis limits:
■■
Hip replacement and
other major joints R23 800
■■
■■
Minor joints R9 800
Orthopaedic and medical
appliances
100% Scheme tariff.
Pathology
100% Scheme tariff.
Diagnostic imaging
100% Scheme tariff.
Oncology
Peritoneal dialysis and
haemodialysis
Confinements
Refractive surgery
100% Scheme tariff.
100% Scheme tariff.
100% Scheme tariff.
100% Scheme tariff. Limited to R7 000 per eye.
100% Scheme tariff.
100% Scheme tariff.
Co-payments
100% Scheme tariff.
Not applicable.
19
Benefits mentioned below may be subject to pre-authorisation and clinical protocols.
Pace1
Pace2
Pace3
Pace4
M = R8 450,
M1+ = R16 790.
M = R11 740,
M1+ = R24 100.
M = R15 000,
M1+ = R31 000.
M = R28 000,
M1+ = R45 100.
Savings first.
Limited to M = R1 650,
M1+ = R3 400. (Subject to
overall day-to-day limit)
Savings first.
Savings first.
100% Scheme tariff.
M = R2 700, M1+ = R7 950.
(Subject to overall day-today 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.
Savings first.
savings account.
then limit.
pre-authorisation.
Savings first.
savings account.
then limit.
pre-authorisation.
100% Scheme tariff. Limited
to M = R5 450, M1+ = R9 350.
Medical aids, apparatus
and appliances
including wheelchairs
and hearing aids
family. (Subject to overall dayto-day limit)
family. (Subject to overall dayto-day limit).
family. (Subject to overall dayto-day limit).
to R7 750 per family. (Subject
to overall day-to-day limit).
Limit on wheelchairs of
R10 500 per family per
48 months.
48 months.
Limit on hearing aids of R21
400 per beneficiary per 24
months.
Limit on hearing aids of R24
100 per beneficiary per 24
months.
Pace
GP and specialist
consultations
Limit on hearing aids of
R26 800 per beneficiary per
24 months.
Savings first.
Savings first.
Savings first.
Wound care benefit (incl.
dressings and negative
pressure wound therapy
(NPWT) treatment and
related nursing services
- out-of-hospital)
day-to-day limit)
day-to-day limit)
day-to-day limit)
Limited to R10 300 per
day-to-day limit)
Optometry benefit
(PPN capitation provider)
■■
■■
■■
Diagnostic imaging
and pathology
Consultation R325
Frame R550 AND
−− Single vision lenses
R150 OR
−− Bifocal lenses R325 OR
−− Multifocal lenses R600
tariff. Limited to M = R2 450,
Maternity benefits
■■
■■
■■
Consultation R325
Frame R550 AND
R150 OR
■■
■■
■■
Consultation R325
Frame R550 AND
R150 OR
■■
■■
■■
Consultation R325
Frame R1 050 AND
R150 OR
to M = R4 200, M1+ = R8 250.
100% Scheme tariff. 2 sonars and up to 12 antenatal consultations.
Specialised diagnostic
imaging
100% Scheme tariff.
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.
Oncology
20
48 months.
Medicine
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.
Pace1
Pace2
Pace3
Pace4
100% Scheme tariff.
100% Scheme tariff.
100% Scheme tariff.
100% Scheme tariff.
Non-CDL chronic
medicine
10 conditions.
85% Scheme tariff.
M1+ = R13 080.
31 conditions.
85% Scheme tariff.
M1+ = R17 900.
31 conditions.
85% Scheme tariff.
M1+ = R28 750.
45 conditions.
85% Scheme tariff.
M1+ = R38 950.
No benefit.
Limited to R123 500
per beneficiary.
Limited to R247 000
per beneficiary.
Limited to R365 450
per beneficiary.
Savings first.
Savings first.
Savings first.
Limited to M = R990,
M1+ = R10 300. Subject
to MRP (10% co-payment)
(Subject to day- to-day
overall limit)
high-cost medicine
Acute medicine
Over-the-counter
(OTC) medicine
Paid from savings. Limited to R500.
Savings account.
Preventative care
Health Check and
■■
■■
■■
■■
Note: Refer to Scheme
rules for funding
criteria applicable to
each preventative
care benefit.
■■
■■
■■
■■
■■
■■
■■
Flu vaccines
Pneumonia vaccines
Female contraceptives –
R1 550 per family
DBC programme
equipment)
Mammogram
HPV vaccines
Health Check
Pap smear – age 18 and
Pace2
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
Flu vaccines
Pneumonia vaccines
Female contraceptives –
R1 550 per family
DBC programme
equipment)
Mammogram
PSA screening – ages
50 and above, every 24
months
HPV vaccines
Health Check
Pap smear – age 18 and
above, every 24 months
One dietician counselling
session per family.
Pace3
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
■■
Pace4
Pace
Pace1
Flu vaccines
Pneumonia vaccines
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.
21
Chronic conditions list (CDL)
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.
Pace1
Pace2
Reimbursement for CDL
Reimbursement for non-CDL
Non-formulary co-payment
No. of non-CDL conditions covered
10
25%
30%
31
Asthma
CDL 3
CDL 4
Bronchiectasis
CDL 5
Cardiomyopathy
CDL 6
CDL 7
CDL 8
CDL 9
Crohn's disease
CDL 11
Diabetes insipidus
CDL 12
CDL 13
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
CDL 25
Schizophrenia
CDL 26
CDL 27
Ulcerative colitis
You can save
money by obtaining
pre-authorisation
for planned, inhospital 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.
20%
45
Addison's disease
CDL 2
CDL 10
22
Pace4
85% Scheme tariff
35%
CDL 1
Pace
Pace3
100% Scheme tariff
Chronic conditions list (non-CDL)
Pace1
Pace2
Pace3
Pace4
non-CDL 1
Acne - severe
non-CDL 2
Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD)
non-CDL 3
Allergic rhinitis
non-CDL 4
Eczema
non-CDL 5
non-CDL 6
Gout prophylaxis
non-CDL 7
Endometriosis
non-CDL 8
Major depression
non-CDL 9
non-CDL 10
Chronic anaemia
Polycystic ovarian disease
non-CDL 11
Graves’ disease
non-CDL 12
Obsessive compulsive disorder
Stroke
non-CDL 14
Paraplegia/Quadriplegia (medication to treat)
non-CDL 15
Pulmonary embolism
non-CDL 16
Female menopause
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
Pace
non-CDL 13
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 37
Muscular 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
23
Contributions
Pace1
Income level
Risk
PRINCIPAL MEMBER
ADULT DEPENDANT
CHILD DEPENDANT
Pace2
N/A
R2 209
R3 281
Pace3
Pace4
< R98 500 p.a.
> R98 501 p.a.
N/A
R3 239
R3 890
R5 263
Savings
R552
R579
R571
R687
R163
Total
R2 761
R3 860
R3 810
R4 577
R5 426
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
Risk
R558
R723
R601
R651
R1 233
Savings
R139
R128
R106
R115
R38
Total
R697
R851
R707
R766
R1 271
child dependant*
4
dependant
*You only pay for a maximum of four children. All other children join as beneficiaries of the Scheme free of charge.
Abbreviations
DBC = Documentation Based Care (Back Rehabilitation Programme); DSP = Designated Service Provider; 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.
Pace
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.
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, softbristled one that you replace each month.
24
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.
Pulse
Pulse1
Pulse2
In-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.
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
Accommodation (hospital stay) and theatre fees
Pulse2
100% Scheme tariff at a Netcare DSP hospital.
Take-home medicine
Treatment in mental health clinics
Treatment of chemical and substance abuse
100% Scheme tariff. (Only PMBs).
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.
Organ transplants
100% Scheme tariff.
100% Scheme tariff. (Only PMBs)
Major medical maxillo-facial surgery strictly
related to certain conditions
No benefit.
100% Scheme tariff.
No benefit.
100% Scheme tariff.
100% Scheme tariff.
100% Scheme tariff.
Prosthesis (Subject to preferred provider,
otherwise limits and co-payments apply)
Note: Sub-limit subject to the
above prosthesis limit
a bodily function
Exclusions (Prosthesis sub-limit subject to
preferred provider, otherwise limits and
co-payments apply)
■■
Functional R8 000
■■
Functional R12 500
■■
Vascular R18 650
■■
Vascular R29 150
■■
■■
■■
■■
Spinal R29 150
■■
Spinal R18 650
■■
■■
■■
Drug-eluting stents R12 800
■■
Drug-eluting stents - no benefit
■■
Mesh R12 800
■■
Mesh R6 800
■■
■■
■■
■■
■■
Joint replacements:
−− Hip replacement and other major joints R34 800
−− Knee replacement R40 700
No benefit.
Not applicable.
Joint replacement surgery (except for PMBs).
PMBs subject to prosthesis limits:
■■
Hip replacement and other major joints R19 150
■■
■■
Orthopaedic and medical appliances
Pulse
100% Scheme tariff.
Limited to 21 days or R24 000 per beneficiary.
Subject to network facilities.
100% Scheme tariff.
Surgical procedures and anaesthetics
Minor joints R9 050
100% Scheme tariff. Limited to R4 850 per family.
100% Scheme tariff.
Pathology
100% Scheme tariff.
Diagnostic imaging
100% Scheme tariff.
Oncology
Peritoneal dialysis and haemodialysis
100% Scheme tariff.
DSP: State Facilities.
Refractive surgery
100% Scheme tariff. National Renal Care. (NRC)
Confinements
26
100% Scheme tariff.
No benefit.
Pulse1
Pulse2
100% Scheme tariff.
100% Scheme tariff.
100% Scheme tariff.
Co-payments
Co-payment of up to R10 000 per event for voluntary
use of a non-DSP hospital.
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.
Note: 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.
GP consultations
Specialist consultations
Basic and specialised dentistry
Pulse1
Pulse2
N/A
M = R11 350, M1+ = R22 550.
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.
(Subject to overall day-to-day limit)
Basic dentistry: Subject to Provider Network.
Basic: According to NP tariff list. 100% Scheme tariff.
(Subject to overall day-to-day limit).
Specialised dentistry: No benefit.
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.
No benefit.
Limited to M = R3 200, M1+ = R6 300.
Wound care benefit (incl. dressings
and negative pressure wound therapy
(NPWT) treatment and related nursing
services - out-of-hospital)
No benefit.
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.
No benefit.
Subject to pre-authorisation.
MRI/ CT scans: A maximum of 3 scans per beneficiary.
PET scans: 1 scan per beneficiary.
DSP: State Facilities.
Diagnostic imaging and
pathology
Oncology
Rehabilitation services after trauma
Pulse
Medical aids, apparatus and appliances
including wheelchairs and hearing aids
No benefit.
27
Medicine
Note: 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.
Pulse1
Pulse2
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.
Co-payment of 25% for non-formulary medicine.
high-cost medicine
No benefit.
Limited to R116 200 per beneficiary.
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)
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 acute
medicine formulary and reference price.
(Subject to overall day-to-day and acute medicine limit)
Acute medicine
Over-the-counter (OTC) medicine
We perceive trust
as a fundamental
requirement of life
which originates
from a commitment
to approach all
relationships with
honesty and integrity.
Additional Scheme
benefits on the
Pulse options
include international
travel cover and
preventative care.
Pulse
Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and MRP/MMAP. DSPs may apply.
Pulse1
Preventative care
Health Check and
■■
■■
■■
■■
Note: Refer to Scheme rules for
funding criteria applicable to each
preventative care benefit.
Flu vaccines
Pneumonia vaccines
Pulse2
■■
■■
■■
■■
■■
■■
Flu vaccines
Pneumonia vaccines
DBC programme
Disclaimer on exclusions: General and option specific exclusions apply. Please refer to www.bestmed.co.za for more details.
28
Chronic conditions list (CDL & non-CDL)
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.
Pulse1
Reimbursement
for CDL
Reimbursement
for non-CDL
Non-formulary
co-payment
No. of non-CDL
conditions covered
Pulse2
Pulse1
100% Scheme tariff
Acne - severe
Attention deficit disorder/
Attention deficit
hyperactivity disorder
(ADD/ADHD)
Allergic rhinitis
No benefit
100% Scheme tariff
non-CDL 2
35% for non-formulary
medicines prescribed by
a specialist
25%
non-CDL 3
No benefit
25
Pulse2
non-CDL 1
non-CDL 4
Eczema
non-CDL 5
non-CDL 6
Gout prophylaxis
CDL 1
Addison's disease
non-CDL 7
Endometriosis
CDL 2
Asthma
non-CDL 8
Major depression
CDL 3
non-CDL 9
Chronic anaemia
CDL 4
Bronchiectasis
CDL 5
Cardiomyopathy
CDL 6
CDL 7
CDL 8
CDL 9
non-CDL 10
Polycystic ovarian
disease
non-CDL 11
Obsessive compulsive
disorder
non-CDL 12
Stroke
non-CDL 13
Pulmonary embolism
non-CDL 14
Female menopause
non-CDL 15
Benign prostatic
hypertrophy
CDL 10
Crohn's disease
CDL 11
Diabetes insipidus
CDL 12
non-CDL 16
Osteoporosis
CDL 13
non-CDL 17
Psoriasis
CDL 14
Dysrhythmia
non-CDL 18
Urinary incontinence
CDL 15
Epilepsy
non-CDL 19
Paget’s disease
non-CDL 20
Gastro oesophageal
reflux disease (GORD)
non-CDL 21
Hypophyseal adenoma
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
CDL 25
Schizophrenia
CDL 26
CDL 27
Ulcerative colitis
non-CDL 22
Osteoarthritis
non-CDL 23
Alzheimer's disease
non-CDL 24
Aplastic anaemia
non-CDL 25
Neuropathy
Pulse
With us you get
the best when
it comes to
accessing quality
healthcare.
29
Contributions
Pulse1
PRINCIPAL MEMBER
ADULT DEPENDANT
CHILD DEPENDANT
Pulse2
Income level
R0 – R6 000 p.m.
R6 001 – R10 000 p.m.
> R10 001 p.m.
N/A
Risk
R1 131
R1 357
R1 630
R3 902
Savings
R0
R0
R0
R0
Total
R1 131
R1 357
R1 630
R3 902
Risk
R1 075
R1 290
R1466
R3 902
Savings
R0
R0
R0
R0
Total
R1 075
R1 290
R1 466
R3 902
Risk
R679
R814
R814
R927
Savings
R0
R0
R0
R0
Total
R679
R814
R814
R927
child dependant*
Not applicable.
4
dependant
Not applicable.
*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; 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.
Pulse
30
Notes
31
General contact details
086 000 2378
[email protected]
012 472 6500
www.bestmed.co.za
@BestmedSocial
www.facebook.com/
BestmedMedicalScheme
WALK-IN FACILITY
Block A, Glenfield Office Park
361 Oberon Avenue
Faerie 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:
E-mail: 080 022 0106
[email protected]
BESTMED HOTLINE, OPERATED BY KPMG
Should 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]
Postal: KPMG Hotpost at BNT 371
P. O. Box 14671, Sinoville, 0129, South Africa
CARECROSS HEALTH (PULSE OPTIONS ONLY)
Tel:
021 673 1848
Website: www.carecross.co.za
Fax: 021 413 1805
CHRONIC MEDICINE (BEAT AND PACE OPTIONS)
CARECROSS CHRONIC MEDICINE (PULSE OPTIONS ONLY)
Tel:
E-mail: Fax: Tel:
E-mail: Fax: 086 000 2378
[email protected]
012 472 6760
CLAIMS
Tel:
E-mail:
086 010 2182
[email protected]
021 673 1815
CARECROSS BENEFIT CLAIMS (PULSE OPTIONS ONLY)
086 000 2378
[email protected] (queries)
[email protected] (claim submissions)
SOCIAL MEDIA
Website:www.bestmed.co.za
Facebook:www.facebook.com/BestmedMedicalScheme
Twitter:@BestmedSocial
Tel:
E-mail: MATERNITY CARE
Tel:
E-mail: 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).
705485 Bestmed Comparative Guide 07/10/2015
086 010 3491
[email protected]
086 111 1936
[email protected]

2016 Bestmed Comparative Guide

Transcription

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