701648 Comparative Guide Final Web

8/2/2019 701648 Comparative Guide Final Web

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IN ASSOCIATION WITH THE GROUP

Cmparavgud

PaceBa

Pulse


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Why chs Bsmd

At Bestmed we pride ourselves on paying 99.2% o all claims within

15 days. Thats just one o the reasons why we have been around or 47

years, oering you quality healthcare, exibility and reedom o choice.

Our partnership with Sanlam ensures that you will have access to top class

service, arming our place as the trusted healthcare partner.

Rest assured your health is in stable hands, because our reserve ratio is

32.4%, well above the legal limit o 25%. At Bestmed we have you covered.

2012 Hahcar rng

We are a scheme managed by members or members and will never compromise

on quality service to you, we always strive to exceed your expectations.

Bestmed provides great healthcare benefts to more than 145 000 members

through our nine unique and exible beneft options. With us you get the best

when it comes to accessing quality healthcare.

Beat range oers ull hospital benefts with limited savings to pay or out-o-hospital expenses, on some options. The options in this category are Beat1,

Beat2 and Beat3.

Pace range oers ull hospital benefts, but with unds rom the Scheme and

more savings to cover extensive out-o-hospital expenses. The options in this

category are Pace1, Pace2, Pace3 and Pace4.

Pulse range oers ull hospital benefts with out-o-hospital benefts provided

by designated network providers only. The options in this category are Pulse1

and Pulse2.

For complete inormation about these options, please reer to the combined

product brochure or go to www.bestmed.co.za

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PULSEPACEBEATBeat1 Beat2 Beat3 Pace1 Pace2 Pace3 Pace4 Pulse1 Pulse2

IN-HOSPITAL BENEFITS (Subject to pre-authorisation)

Accommodation (hospitalstay) and theatre ees

100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari.

Take home medicine 100% Bestmed tari.Limited to 7 days medicine.

100% Bestmed tari.Limited to 7 days medicine.








Treatment in mentalhealth clinics

100% Bestmed tari.Limited to 21 days per benefciary.



100% Bestmed tari.Limited to 21 days perbenefciary.






Treatment o chemicaland substance abuse

100% Bestmed tari.Limited to 21 days or R15 500per benefciary.







100% Bestmed tari.Limited to PMB conditions.


Consultations andprocedures


Surgical proceduresand anaesthetics orsurgical procedures andoperations

100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. Excludedrom benefts: unctional nasalsurgery, surgery or medicalconditions e.g. Epilepsy,Parkinsonism etc, Procedureswhere stimulators are used

100% Bestmed tari.

Organ transplants 100% Bestmed tari.Subject to pre-authorisationand protocols (only PMBs).

100% Bestmed tari.Subject to pre-authorisationand protocols (only PMBs).

100% Bestmed tari.Subject to pre-authorisationand protocols (only PMBs).

100% Bestmed tari.Subject to pre-authorisation andprotocols.

100% Bestmed tari.Subject to pre-authorisationand protocols.





Dentistry-Maxillo-acialsurgery strictly relatedto certain conditions

100% Bestmed tari.Limited to R7 100 per amilyper year.




100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. No beneft. 100% Bestmed tari.

Prosthesis - Internal 100% o cost.Limited to R43 000 per amily.Sub-ms pr bnfcary:Vascular R16 500Endovascular - no beneftSpinal R16 500Artifcial disk, single level based

- no beneftDrug eluting stents - no

beneftsMesh R5 900

Gynaecology/Urology R4 800Lens implants R3 700 per lens

100% o cost.Limited to R43 000 per amily.Sub-ms pr bnfcary:Vascular R16 500Endovascular - no beneftSpinal R16 500Artifcial disk, single level based


beneftsMesh R5 900




beneftsMesh R5 900




beneftsMesh R6 400


100% o cost.Limited to R65 000 per amily.Sub-ms pr bnfcary:Vascular R23 000Spinal R23 000Artifcial disk, single level

based, R10 000Drug eluting stents R10 000Mesh R10 000Gynaecology/Urology R7 500Lens implants R6 500 per lens

Joint Replacements:Hip prosthesis and othermajor joints R27 000Knee prosthesis R32 000Other minor joints R12 000

100% o cost.Limited to R65 000 per amily.Sub-ms pr bnfcary:Vascular R23 000Spinal R23 000Artifcial disk, single level based,

R10 000Drug eluting stents R10 000Mesh R10 000Gynaecology/Urology R7 500Lens implants R6 500 per lens


100% o cost.Limited to R75 000 per amily.Sub-ms pr bnfcary:Vascular R26 700Spinal R26 700Artifcial disk, single level based,

R11 800Drug eluting stents R11 800Mesh R10 700Gynaecology/Urology R8 500Lens implants R 9 600 per lens




beneftsMesh R5 400


100% o cost.Limited to R65 000 per amily.Sub-ms pr bnfcary:Vascular R23 000Spinal R23 000,Artifcial disk, single level based,

R10 000Drug eluting stents R10 000Mesh R10 000Gynaecology/Urology R7 500Lens implants R6 500 per lens


Abbrvans: PMB = Prscrbd Mnmum Bnf In-hospitalbenefts


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IN-HOSPITAL BENEFITS CONT. (Subject to pre-authorisation)

Prosthesis - External R10 700 per amily. R10 700 per amily. R10 700 per amily. R13 000 per amily. R15 000 per amily. R15 000 per amily. R17 000 per amily. No beneft. R15 000 per amily.

Orthopaedic andmedical appliances

No beneft. Savings Account. Savings Account. As per out-o-hospital medicalapparatus.

As per out-o-hospital medicalapparatus.



100% o cost limited to R4 300per amily.


Pathology 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari.

Diagnostic Imaging 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari.

Specialised DiagnosticImaging


Oncology Oncology Programme.100% Bestmed tari.Subject to pre-authorisation.

Oncology Programme.100% Bestmed tari.Subject to pre-authorisation.








Peritoneal dialysis and

haemodialysis

100% Bestmed tari.

Subject to pre-authorisationand protocols.

100% Bestmed tari.


100% Bestmed tari.


100% Bestmed tari.

Subject to pre-authorisation.and protocols.

100% Bestmed tari.


100% Bestmed tari.


100% Bestmed tari.


100% Bestmed tari.


100% Bestmed tari.


Confnements 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari.

Breast Reduction 100% Bestmed tari.Subject to pre-authorisationand protocols.






100% Bestmed tari.Limited to R10 700 per amily.Subject to pre-authorisationand protocols.



Reractive Surgery 100% Bestmed tari.Subject to pre-authorisationand protocols.






100% Bestmed tari.Limited to R10 700 per amily.Subject to pre-authorisationand protocols.



Supplementary Services 100% o Bestmed tari. 100% o Bestmed tari. 100% o Bestmed tari. Physiothera py and Biokeneticslimited to M = R4 300 M+ =R6 400.

100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari. 100% Bestmed tari.

Alternatives tohospitalisation

100% Bestmed tari.Limited to R10 700 peramily per year.


100% Bestmed tari iauthorised.







Emergency Evacuation 100% Cost.Rendered and pre-authorisedby ER24.

100% Cost.Rendered and pre-authorisedby ER24.








In-hospitalbenefts

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IN-HOSPITAL BENEFITS CONT. (Subject to pre-authorisation)

Exclusions(In-hospital)

Joint Replacement Surgery(except or PMBs).PMBs subject to prosthesis limits:Hip prosthesis and other major

joints R19 000Knee replacement R23 500Other minor joints R8 000







N/a N/a N/a Joint Replacement Surgery(except or PMBs).PMBs subject to prosthesis limits:Hip replacement R17 000Knee replacement R21 500other minor joints R8 000

N/a

Co-payments(In-hospital)

Co-payment o R1 000 on allendoscopic investigations. I donein Dr rooms (out-o-hospital) noco-payment.



N/a N/a N/a Shoulder surgery R1 200 Joint Replacement R1 200Laparoscopic nissen R1 200Spinal surgery R1 200Hysterectomy R800Arthroscopy R400

Co-payments where procedure hasbeen clinically approved: R2 500on all laparoscopic procedures,R 3 000 on hip and kneereplacements, R 2 500 on prostateprocedures, R 2 500 on proceduresor prolapse/incontinence, R 2 500on arthroscopy other than acutetrauma, R 2 000 on endoscopyinvestigationsdoneprimarilyinhospital.

N/a

Abbrvans: PMB = Prscrbd Mnmum Bnf

In-hospitalbenefts

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OUT-OF-HOSPITAL BENEFITS

Out-o-Hospital Benefts Day-to-day beneftM=R7 000 M1+= R14 000

Day-to-day beneftM=R10 000 M1+= R20 000



GP and SpecialistConsultations

N/a Savings Account Savings Account Limited to M=R1 200,M1+=R2 400(Subject to day-to-day overalllimit)

Limited to M=R2 500,M1+= R5 000(Subject to day-to-dayoverall limit)

Limited to M= R2 000,M1+= R6 000

Limited to M=R3 200,M1+=R5 200(Subject to day-to-day overalllimit)

Subject to Provider NetworkGP visits limited to 7consultations per benefciary perannum (except or PMBs).Three specialist visits R1 000 pervisit per amily per year (NetworkProvider tari), pre-authorisationand reerral by NP required.Two out o Network GP visits peramily per year limited to R700per visit with 20% co-payment.

Unlimited ONECARE GPconsultations.Specialist consultations must bereerred and approved by NP.Limited M=R2 000, M1+=R4 000(Subject to day-to-day overalllimit)

Two out o Network GP visits peramily per year limited to R1 000as approved by NP.

Basic and SpecialisedDentistry

N/a Basic dentistry - according topreventative beneft or savingsaccount.Specialised dentistry - SavingsAccount.

Basic dentistry - according topreventative beneft or savingsaccount.Specialised dentistry - SavingsAccount.

Limited to M=R2 100,M1+= R4 200(Subject to day-to-day overalllimit)

Limited to M=R3 500,M1+= R7 000(Subject to day-to-dayoverall limit)

Basic: Subject to Savings AccountSpecialised: 100% o Bestmedtari, Orthodontic treatmentsubject to pre-authorisationLimited to M=R3 700,M1+= R6 400

Limited to M=R6 400,M1+= R10 700(Subject to day-to-day overalllimit)

Basic dentistry: Subjectto Provider NetworkSpecialised dentistry: No beneft.

Basic: According to NP tari list.(Subject to day-to-day overalllimit)Specialised: 100% o Bestmedtari, subject to pre-authorisationand day-to-day beneft.Limited to M=R4 300M1+= R5 400

Medical Apparatus N/a Savings Account Savings Account 100% o cost Limited to R6 400per amily

Limited to R15 000 per amilySub-limit on wheel chairs= R8 500 per amilySub-limit on hearing aids= R14 000 per benefciary per48 months.

Limited to R15 000 per amilySub-limit on wheel chairs =R8 500 per amilySub-limit on hearing aids =R14 000 per benefciary per48 months.

Limited to R19 300 per amilySub-limit on wheel chairs= R8 600 per amilySub-limit on hearing aids=R15 000 per benefciary per48 months.

Subject to Provider Network Limited to R15 000 per amily.Sub-limit on wheelchairs= R8 500 per amily. Sub-limiton hearing aids = R14 000 perbenefciary per 48 months.

Supplementary Services N/a Savings Account Savings Account Limited M=R2 600, M1+=R5 200(Subject to day-to-day overalllimit)

Limited M=R3 500,M1+ = R7 000(Subject to day-to-dayoverall limit)

Savin gs Acco unt Limited M=R3 200, M1+=R6 400(Subject to day-to-day overalllimit)

No beneft Limited M=R2 500, M1+=R5 000(Subject to day-to-day overalllimit) NP list

Wound care treatmentbeneft

Limited to R2 000 per amily. Limited to R2 000 per amily. Limited to R2 000 per amily. Limited to R2 000 per amily.(Subject to day-to-day overalllimit.)

Limited to R4 000 per amily.(Subject to day-to-dayoverall limit.)

Limited to R6 000 per amily. Limited to R8 000 per amily. Subject to Provider Network Limited to R6 000 per amily.

Abbrvans: M = Mmbr, M1+= Mmbr and amy, NP = Nwrk prvdr, PMB = Prscrbd Mnmum Bnf

Out-o

-hospitalbenefts

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OUT-OF-HOSPITAL BENEFITS CONT.

Optometry Services N/a Savings Account As per PPN agreement:Consultation R505Frame R500Single vision R130 per lensBiocal R290 per lensMultiocal R530 per lens ORContact lenses R1 160

Once every 24 months/two years:Limited M=R1 300, M1+=R2 600(Subject to day-to-day overalllimit)

One per benefciary per24 months/two years.Sub-limits apply

One per benefciary per 24months/two years.Sub-limits apply

Limited M=R3 200, M1+=R5 400Frames limited to R1 000 perbenefciary per 24 months/two years.(Subject to day-to-dayoverall limit)

Subject to Provider Network Subject to optical managementprogramme.Limited M=R2 500, M1+=R4 000(Subject to day-to-dayoverall limit)

Frames R 500 R 500 Subject to Provider Network

Other (Lenses) One eye test per benefciary per24 months.The ollowing sub-limits apply: Frames R500 Sige visi eses R550 High pwer eses R1 100 Bifca eses R1 600 Verifca eses R2 100

r Ctact eses R1 600

One eye test per benefciary per24 months.The ollowing sub-limits apply: Frames R500 Sige visi eses R550 High pwer eses R1 100 Bifca eses R1 600 Verifca eses R2 100

r Ctact eses R1 600

Subject to Provider Network

Diagnostic Imaging N/a Savings Account Savings Account Limited M=R1 900, M1+=R3 800(Subject to day-to-day overalllimit)

Limited M=R1 800,M1+ = R3 600(Subject to day-to-dayoverall limit)

M= R2 000, M1+= R4 000 Limited M=R3 200, M1+=R6 400(Subject to day-to-dayoverall limit)

Subject to Provider Network Subject to NP protocols andtari list.Pre-authorisation required(Subject to day-to-dayoverall limit)

Pathology N/a Savings Account Savings Account

Maternity Benefts N/a Savings Account 2 sonars and up to 12 antenatalconsultations

Combined limit include GP,Specialist.




Subject to Provider Network Combined limit include GP,Specialist

Specialised DiagnosticImaging

N/a Savings Account 100% Bestmed tari.Limited to R6 400 per amily.

100% o Bestmed tari.Limited to R8 500 per amily.

Subject to pre-authorisationMRI/CT scans: Maximum othree scans per benefciary.PET scan: One scan perbenefciary.

Subject to pre-authorisationMRI/CT scans: Maximum o threescans per benefciary.PET scan: One scanper benefciary.

Subject to pre-authorisationMRI/CT scans: Maximum o threescans per benefciary.PET scan: One scan perbenefciary.

Subject to Provider Network Subject to pre-authorisationand NP list.MRI/CT scans: Maximum o threescans per benefciary.PET scan: One scan perbenefciary.

Rehabilitation servicesater trauma

N/a Savings Account Savings Account Bonus Account 100% Bestmed tari.Subject to pre-authorisationand protocols.



No beneft N/a

Abbrva ns: M = Mmbr, M1+= Mmbr and amy, NP = Nwrk prvdr, PPN = Prrrd prvdr nwrk

Out-o

-hospitalbenefts

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MEDICINE

Non-CDL chronicSubject to MRP

N/a Savings Account 5 conditions 85% o Scheme tariapplies limited toM=R2 100, M1+=R4 200Subject to medicine reerenceprice and ormularies.Co-payment o 35% ornon-ormulary medicines.

15 conditions 85% o Schemetari applies limited toM=R5 700, M1+= R11 400Subject to medicine reerenceprice and ormularies.Co-payment o 35% ornon-ormulary medicines.

31 conditions 85% o Schemetari applies limited toM=R7 000, M1 += R14 000Subject to medicine reerenceprice and ormularies.Co-payment o 30% ornon-ormulary medicines.

31 conditions 85% o Schemetari applies limited toM=R11 300, M1+= R22 600Subject to medicine reerenceprice and ormularies.Co-payment o 25% ornon-ormulary medicines.

45 conditions 85% o Schemetari applies limited toM=R15 500, M1+ = R31 000Subject to medicine reerenceprice and ormularies.Co-payment o 20% ornon-ormulary medicines.

Unlimited.Subject to Provider NetworkFormulary and reerence price

45 conditions 100% o Schemetari applies i prescribed by a NP.Limited to M=R8 000,M1+= R16 000.Subject to NP and ormularies.Co-payment o 25% ornon-ormulary medicines.

CDLSubject to MRP

100% o Bestmed tari.Subject to medicine reerenceprice and ormularies.Co-payment o 35% ornon-ormulary medicines.








100% o Bestmed tari.Subject to NP and ormularies.Co-payment o 25% ornon-ormulary medicines.

Biological N/a No beneft No beneft No beneft Subject to pre-authorisationlimited to R100 000 per

benefciary

Subject to pre-authorisationlimited to R200 000 per

benefciary

Subject to pre-authorisationlimited to R300 000 per

benefciary

No beneft Subject to pre-authorisationlimited to R100 000 per

benefciary.Acute N/a Savings Account Savings Account Limited M=R1 500, M1+=R3 000

Subject to medicine reerenceprice and ormularies.(10% co-payment)(Subject to day-to-day overalllimit)

Limited M=R3 000,M1+ = R6 000Subject to medicine reerenceprice and ormularies.(10% co-payment)(Subject to day-to-dayoverall limit)

Limited M=R750, M1+=R2 000Subject to medicine reerenceprice and ormularies.(10% co-payment)

Limited M=R5 200, M1+=R8 300Subject to medicine reerenceprice and ormularies.(10% co-payment)(Subject to day-to-dayoverall limit)


Subject to Provider NetworkFormulary and reerence priceLimited M=R3 000, M1+=R6 000(Subject to day-to-dayoverall limit)

Over the Counter N/a Savings Account Savings Account Limited R500(Subject to day-to-day acutemedicine limit)

Limited R1 000(Subject to day-to-day acutemedicine limit)

Savings Account Limited R1 000(Subject to day-to-day acutemedicine limit)

Limited to R180 per amily peryear with a maximum o R60per event and three events.Designated pharmacy only.

Limited to R1 000 per amilysubject to acute medicineormulary + reerence price.(Subject to day-to-day acutemedicine limit)

Abbrvans: M = Mmbr, M1+= Mmbr and amy, NP = Nwrk prvdr

Med

icine

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PREVENTATIVE CARE BENEFITS

Preventative benefts Flu vaccines,* Pneumonia programme,

Paediatric immunisations,Contraceptives - R1 200 ppa,

* DBC programme.

Flu vaccines,* Pneumonia programme,


* DBC programme,Preventative Dentistry (incl.gloves and sterile equip).



* DBC programme,Preventative Dentistry (incl.gloves and sterile equip).



* DBC programme,Preventative Dentistry (incl.gloves and sterile equip).HIBtitre,

* Mammogram,* PAP smear.



* DBC programme, PSA,Preventative Dentistry (Inclgloves and sterile equip),HIB titre,

* Mammogram,* PAP smear.



* DBC programme,Preventative Dentistry (Inclgloves and sterile equip),HIB titre,

* Mammogram,* PAP smear.* PSA, Lipogram

Bone Densitometry.



* DBC programme,Preventative Dentistry (inclgloves and sterile equip),HIB titre,*Mammogram,

* PAP smear,* Lipogram,* PSA,

Bone Densitometry.


Paediatric immunisations.


Paediatric immunisations,* DBC programme.

*Cditis appy. Fr detais, refer t the reevat beet gide i the prevetative care secti.

Preventativecarebenefts

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11/13

Contributions

OPTION 2012 CONTRIBUTIONS

Principal Member Adult Dependant Child Dependant

Income level: (pa) Risk Savings Total Risk Savings Total Risk Savings TotalMaximum Contribution

Child Dependant

Recognition o a

Child DependantLoyalty Rewards Programme

Ba1 N/a R802 R0 R802 R624 R0 R624 R338 R0 R338 4 Under 21 unless registered student Reality

Ba2 N/a R802 R142 R944 R624 R110 R734 R338 R60 R398 4 Under 21 unless registered student Reality

Ba3 N/a R1 250 R256 R1 506 R888 R182 R1 070 R482 R99 R581 4 Under 21 unless registered student Reality

Pace1 N/a R1 549 R437 R1 986 R1 088 R307 R1 395 R390 R110 R500 4 Under 21 unless registered student Reality


Pace3 < R92 000 R2 177 R478 R2 655 R1 743 R383 R2 126 R403 R89 R4924 Under 21 unless registered student Reality

> R92 001 R2 615 R574 R3 189 R2 090 R459 R2 549 R438 R96 R534


Pulse1 < R13 000 R741 R0 R741 R741 R0 R741 R442 R0 R442

N/a Under 21 unless registered student RealityR13 001 - R51 000 R796 R0 R796 R751 R0 R751 R442 R0 R442

R51 001 - R65 000 R1 006 R0 R1 006 R768 R0 R768 R442 R0 R442

> R65 001 R1 119 R0 R1 119 R856 R0 R856 R475 R0 R475

Pulse2 N/a R2 876 R0 R2 876 R2 876 R0 R2 876 R684 R0 R684 4 Under 21 unless registered student Reality

P Principal Member A Adult Dependant C Child Dependant* Yu ny pay r a maxmum ur chdrn. A hr chdrn jn as bnfcar s n h Schm r charg.

page21page20


12/13

Ns:

I N A SSO CI AT IO N W IT H T HE GR OU P

CoNtACt DetAilS

Gnrat: 086 000 2378e-ma: [email protected]: 012 472 6500

Wak-n acyBlock A, Glenield Oice Park, 361 Oberon Avenue,Faerie Glen, Pretoria 0081

Psa addrssPO Box 2297, Arcadia, Pretoria, 0001

Camst: 086 000 2378e-ma: [email protected] (queries)

[email protected] (claim submissions)

Hspa auhrsant: 0800 22 0106e-ma: [email protected]

CDl chrnc mdcant: 086 000 2378e-ma: [email protected]: 012 472 6760

ER 24 ad iteratia trave cvert: 084 124

BsBabyt: 011 704 0072e-ma: [email protected]

HIV/AIDS prgrammet: 011 251 9400e-ma: [email protected]

[email protected]: 086 500 9822

oncgy prgrammt: 012 472 6254e-ma: [email protected]

onn srvc accss and qurse-ma: [email protected]

Wbma (-ma acy)e-ma: [email protected]

Wbs chnca ssuse-ma: [email protected]

CounCIl FoR MEDICAl SCHEMES

Cusmr Car Srvc Cnrt: 0861 123 267

e-ma nqurse-ma: [email protected]

e-ma cmpanse-ma: [email protected]

Bestmed is administered by Sanlam, one o South Aricasleading inancial services groups, with an enviable trackrecord o providing products and services that embodytheir values o trust, honesty, integrity and caring.Like Sanlam, Bestmed continually strives to oer thebest with value-or-money products supported bysuperior client service to make your dealings withBestmed eicient and to your satisaction. I you arenot satisied with Bestmeds service, e-mail your complaintto [email protected] or alternatively to the Councilor Medical Schemes, [email protected]


13/13

www.bestmed.co.zaDscamr: Whilst Bestmed has taken all reasonable care

in compiling this beneft guide, we cannot accept liability or

any errors or omissions contained herein. Please note that

should a dispute arise, the registered Rules o Bestmed as

approved by the Registrar o Medical Schemes shall prevail.

Please visit www.bestmed.co.za or the complete liability and

responsibility disclaimer or Bestmed Medical Scheme.

2011/09/15-01Comparative Guide

Documents

701648 Comparative Guide Final Web