Bestmed Medical Scheme - Aon South Africa · 2019. 10. 8. · Your Guide to Bestmed 4 Bestmed...

When life happens, Bestmed Medical Scheme is there to assist

Bestmed Medical Scheme

Bestmed Corporate Profile 04

Bestmed Workplace Wellness Framework 06

Our preventative care benefit 09

Find out more about the MSA & vested savings 10

Broker Support

Meet the broker consultant team 12

The Bestmed broker online experience 14

Your healthcare happiness is only a click away -

Member portal 15

The Bestmed member mobile App 16

Improved Escalation Process

The long wait is over! 17

Our new business process 18

Our benefits and programmes

In an emergency? Contact ER24 20

Travelling overseas? We’ve got you covered 22

What you need to know about medicine 23

Dental benefits 29

Optical benefits: See more with Bestmed 31

Radiology benefit 34

Oncology programme 35

HIV/Aids programme 37

Back and neck programme (DBC) 39

Maternity Care 40

Use the Bestmed provider network and get more value 42

Underwriting concession for new members at

existing groups 43

Contraceptive list 44

Vaccine Schedule 47

Contact Us 50

Table of

contents

Your Guide to Bestmed 4

Bestmed

Corporate

Profile

Bestmed was established in 1964 and currently has approximately 200 000 lives under its care. The Scheme is the largest self-administered scheme in South Africa and the fourth largest open medical scheme. We offer 13 plans to suit every life stage and pocket.

Bestmed is a self-administered Scheme therefore we do not make use of a for-profit administrator. This

allows us to keep our administration costs 3 – 5% lower than our competitors. We aim to offer the best pos-

sible service to our members and we were voted third on the client service satisfaction benchmark by the

Ask Africa Orange Index 2018. Four of our options have been selected as the best performers within the

South African medical scheme market (2018 GTC Medical Aid Survey).

Our excellent service provider network differentiates us from the rest of the market. We offer access to

an extensive national network consisting of more than 4000 family practitioners and 15 000 network

provider agreements. Members are able to search for a healthcare facility closest to them via the Bestmed

app and website.

Management reporting

Executive Management access

Dedicated Key Account consultants where requested

Participation in wellness days

Seamless integration

Online registrations and member management

Access via contact centre, mobile app, website (with live chat) and on-site service where required

Member training and information sessions

Induction sessions

Unique and tailored solutions

Benefits to the value of R 4,500 per individual and R100,000 per corporate

Includes:

- Health Risk Assessments - Corporate interventions

- Workshops - Nurse assistance

Managed healthcare programmes available to members including HIV/AIDS, oncology, diabetes and maternity benefits.

Why Bestmed for your business?

Management Services Member Services Administration and reconciliation

Tempo Wellness programme Additional Offerings


Beat

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 lower your monthly contribution in

the form of a Network option.

Pace

The 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 seeking

comprehensive cover.

Pulse

The Pulse range is ideally suited for individuals that are:

Seeking a plan option based on their income; com-

fortable with making use of designated service

providers (DSPs) within our network; looking for

unlimited comprehensive cover for hospitalisation

and the added benefit of preventative care cover.

Bestmed Corporate Profile

Bestmed medical aid option ranges


Bestmed

Workplace

Wellness

Framework

We know that your most important resource in your business is your workforce.

Bestmed’s Wellness Programme, Tempo, designs interventions based on scientific analyses to give your business

and its people that sustainable edge.

Lack of employee engagement, a shortage of leadership support and complicated incentives all have the potential

to derail your wellness programme before it starts. Tempo is a wellness programme that helps you thrive, not just

survive. There are no points, no fees, no complications.

Proven outcomes of the Tempo programme

*based on case study in 2017

Mapping of employees’ health risks

Marked decrease in absenteeism

A reduced risk of chronic diseases

Higher productivity as a workforce

Reduction in number of hospital admissions

for those who participate in the programme.

Higher productivity

Happier employees

A more stable workforce

PROVIDING EMPLOYEES WITH RESOURCES TO PURSUE HEALTHY LIFESTYLES LEADS TO


The Bestmed / Tempo workplace wellness model makes provision for the following:

A comprehensive Health Risk Assessment

o The assessment assists in determining what the unique health risks are for each individual (employee),

as well as the risks for the entire staff complement.

o Completion of this assessment is the gateway to access any and all of the interventions listed hereafter.

Assistance with the design of an intervention programme that is aimed at addressing these risk areas.

Arranging, funding and coordinating the interventions as agreed to by the employer organisation.

o Interventions should be group focused and individual focused.

Group interventions or company-wide campaigns are aimed at creating and embedding a healthy

culture within the organisation. Examples of these are:

o Fitness sessions, which may include Aerobics, Pilates, Lunch hour walks.

o Nutrition sessions, which include weight management sessions, 30-day healthy eating challenges,

and food demonstrations.

o Stress management sessions, including increased sleep challenges, workshops.

o "Your Best Year" series of workshops (a series of 5 workshops aimed at providing participants with

the necessary tools and knowledge to set “healthy living” goals and implement these through

the course of a year).

o Wellness Champion Training sessions. Once a participant completes "Your Best Year" workshops, they

can register for the advanced course which will equip them to become wellness champions and drive future

wellness initiatives and activities within the organisation.

o Several challenges and competitions, that are linked to any of the wellness topics, can be coordinated.

These challenges provide that extra element of fun – competing with one another!

All the group interventions and challenges mentioned above are available to all employees, regardless of

their scheme of choice. The programme is however subject to completion of an HRA (health risk assessment)

by Bestmed members.

In addition to the group interventions, Bestmed members have access to individual interventions at a

biokineticists and a dietician. The Scheme can arrange that these providers render their services to

Bestmed members onsite at the employer (a minimum number of interested Bestmed members are required).

In Practice

All interventions and wellness related activities are planned in cooperation with the employer (Human Resources

and/or Employee Wellness departments) to design a plan and schedule for a minimum period of 18 months.

Relevant health topics are chosen as themes for each quarter. These topics are aligned to the Health Calendar

issued by the Department of Health.

The different themes are presented to employees by means of:

An awareness campaign (health promotion communication that can include flyers, posters, emails

and other communication material). This campaign is made available to all employees.

Group interventions or challenges relating to the topic / theme. Available to all employees.

Promotional items that provide an overview of the topic / theme. Available to all employees.


Screens, tests, assessments or individual interventions linked to the specific topic / theme. This is available

to Bestmed members only. Providers can be arranged to render the same services to other schemes’

members at an additional cost.

Satisfaction or feedback survey to rate the employees experience of the specific campaign.

Coordination

As a corporate client of Bestmed, you do not need to coordinate or implement the programme. Bestmed’s

representatives will see to it that what you agreed to is implemented.

Why not give it a try? What do you have to lose?

For more information about a customised workplace wellness programme, please contact Bestmed Tempo at:

E-mail: [email protected]

Telephone: 086 000 2378

Fax: 012 472 6760

www.bestmed.co.za


Benefit

Flu vaccines

Pneumonia vaccines

Paediatric immunisations

Female contraceptives

Back and neck preventative programme

Haemophilus influenzae Type B vaccine (HIB)

Mammogram

HPV vaccinations

PSA Screening

Bone densitometry

Pap smear

Quantity and frequency

1 per beneficiary per year

Children: As per schedule of Department of Health

Adults: Twice in a lifetime with booster above 65 years of age

Funding for all paediatric vaccines according to the state-recommended programme

Quantity and frequency dependent on product and subject to maximum amount.

Mirena - 1 device every 60 months

Subject to pre-authorisation.

1 vaccine for infants at 6, 10 and 14 weeks

1 vaccine booster between 15 - 18 months

Females 40 years and older

Once every 24 months

3 vaccinations per beneficiary. Females 9 - 26 years

Males 50 years and older Once every 24 months

Beneficiaries 45 years and older. Once every 24 months.

18 years and older Once every 24 months

Benefit criteria

Applicable to all active members and beneficiaries

The Scheme will identify high-risk individuals for immunistion

Limited to R2 205 per beneficiary per year.

Preferred providers (DBC/Workability Clinics).

The booster vaccine will be administered up to a maximum age of 5 years

Scheme tariff applies

Vaccinations funded at MRP

Can be done at a urologist or FP. Consultation paid from the available savings/consultation benefit.

At any gynaecologist or FP. Consultation is paid from available savings or consultation benefit

Beat

√

√

√

√

√

*Only available on Beat4

*Only available on Beat2, 3 and 4

√

*Only available on Beat2, 3 and 4

X

√

Pace

√

√

√

√

√

√

√

√

√

Only available on Pace2, 3

and 4

√

Pulse

√

√

√

√

√

X

X

√

X

X

X

Our preventative care benefit

*Only available on Beat2, Beat3

and Beat4


Find out more about the MSA & vested savings

1. What does MSA mean?

It means medical savings account.

2. How is the MSA calculated?

MSA is calculated using the fixed percentage of the total contribution.

3. When do these funds become available?

On 1 January every year (beginning of the financial year)

4. Do all Bestmed plan options have a medical savings account?

No, not all plan options have a medical savings account. The Pulse and Beat1 options do not have this option.

5. Why do I have specified day-to-day benefits if I have a medical savings account?

You first utilise the medical savings account, once that is depleted you will have access to your day-to-day

benefits on specific plan options.

6. What happens when my medical savings account runs out?

On Beat4, Pace1, Pace2 and Pace3 your day-to-day benefits will become available.

7. Can I use the money in the medical savings account to fund co-payments?

No, the medical savings account does not fund co-payments

8. Do I lose the money if I don’t use it?

No you don’t lose it, it becomes a part of the following year's savings or will be added to your vested savings,

depending on which option you are on.

9. Do I earn interest on the money in my medical savings account?

Yes. The Scheme allocates the net interest received on MSA invested funds to members with positive savings balances.

10. What if I never use my medical savings account?

The money will be transferred for you to use the following year. If you resign your membership with Bestmed and

choose not to join another scheme, or if you join a scheme without a savings option, the money will be paid to you.

If you join a scheme with a saving account, the money will be transferred into the new schemes savings account.

11. What is vested savings?

Vested savings are accumulated savings from previous years.

12. How do I access vested savings?

Members can give permission to pay for claims from the vested savings account. Some claims are automatically paid

from vested savings.

Broker

Support


Meet the broker consultant team

Adele Pullen

Gauteng/Polokwane+27 (0) 76 071 [email protected]+27 (0) 12 472 6487

Zerina Richards

Liberty Gauteng- Johannesburg+27 (0) 71 415 [email protected]+27 (0) 12 472 6362

Palesa Skosana

Gauteng+27 (0) 78 277 9374 [email protected]+27 (0) 12 472 6494

Sashni Maharaj

Gauteng+27 (0) 74 172 [email protected]+27 (0) 12 472 6483

Merencia Ellis

Cape Town/ East London+27 (0) 76 900 [email protected]+27 (0) 21 202 8807

Patrick Chauke


Victor Mokwele


Laura Patrick

Kwa Zulu Natal+27 (0) 84 361 [email protected]+27 (0) 31 279 5428

Ritesh Ramdeen

Gauteng/Mpumalanga+27 (0) 76 6255 [email protected]+27 (0) 12 472 6469

Charmaine Mali

Liberty Gauteng- Pretoria+27 (0) 82 954 [email protected]+27 (0) 12 472 6040

Felicia Van Zyl

Gauteng/Free state+27 (0) 76 532 [email protected]+27 (0) 12 472 6467


Meet the broker consultant team - continued

Claudette Jansen

Cape Town+27 (0) 61 350 [email protected]+27 (0) 21 202 8806

Ingrid Visagie

Distribution sales team leader+27 (0) 71 246 [email protected]+27 (0) 12 472 6478


Use your online profile to get access to:

Benefit summaries

View employer groups

View claims

Log a new query and view the status of your previous queries

View members, member plan options, membership status, premiums and broker commission

Update brokerage details

STEPS TO LOG ON TO YOUR ONLINE PROFILE:

Step 1:

Visit the Bestmed website at www.bestmed.co.za

Step 2:

Click on the light green Member/Provider Login tile on the far right of your screen

Step 3:

Click on the “Broker login” tile

Step 4: A new window will open, if you have never registered a profile, click on “New user”

or enter your username and password to sign in

Step 5: If you are a new user you will need to have your broker number handy

Step 6:

You will be asked to select your preferred verification method (SMS/E-mail)

Step 7:

Once you have completed all the required fields you will receive a verification code.

You will need to return to the log in screen to verify your profile

Step 8: Once the verification process is complete you can log on with your username and password

The Bestmed

broker online

experience


Your healthcare happiness is only a click away

Member portal

We have created a whole new world of online services for you.

You can stay in control of your health benefits from the comfort of your home, anytime from anywhere.

The online profile gives you access to:

Benefit summaries

Log a claim

View claims history

Log a query

Request and receive tax certificates

Update personal details

Check status of submitted claims

HOW TO LOG ONTO YOUR PROFILE:

Step 1:

Visit the Bestmed website at www.bestmed.co.za

Step 2:

Click on the light green Member/Provider Login tile on the far right of your screen

Step 3:

Click on the “Member login” tile

Step 4:

A new window will open, if you have never registered a profile, click on “New user”

or enter your username and password to sign in

Step 5:

If you are a new user you will need to have your membership number handy

Step 6:

You will be asked to select your preferred verification method (SMS/E-mail)

Step 7:

Once you have completed all the required fields you will receive a verification code.

You will need to return to the log in screen to verify your profile

Step 8:

Once the verification process is complete you can log on with your username and password


The Bestmed member mobile App

The Bestmed App is easy to download, always at your service, and best of all, it’s free!

7 reasons to download the Bestmed App: 1. A user-friendly home screen loaded with even more tips and tricks

2. You can download your tax certificate

3. Automatic updates on all Scheme communication

4. Easy to access benefit information, including hospital, chronic medicine and savings

5. Submit your chronic medicine application

6. Quick personal details update

7. Search for a specialist in your area

8. Submit claims


The long wait is over!

Our broker support services have been improved to suit your needs.

Avoid the queue and contact our broker support team directly by calling +27 (0) 12 472 7182.

For any other enquiries e-mail [email protected]

Your queries go right to the top

We care about your concerns and unresolved queries, and that is why our escalation process goes

right to the top, to our Executive Manager, Elmarie Jooste.

Elmarie will personally ensure that your escalation is resolved promptly.

Send your escalations to [email protected]

Remember to keep your ticket number handy!

Improved

escalation

process


Our new

business

process

At Bestmed we are passionate about service delivery and we aim to provide our current and prospective members with the best service possible.

This is how our new business process works: 1. The fully completed application form with relevant supporting documents is sent to [email protected]

2. The new application form is indexed to New Business as a workflow by Distribution Support.

3. Application is captured and outstanding requirements are identified and sent to stakeholder for intervention.

The new business consultant applies underwriting as per the Bestmed Scheme Rules.

4. The condition specific waiting period is referred to a medical advisor to process, based on medical history and

supporting documents.

5. The medical advisor applies relevant exclusions and notes.

6. The application is reviewed and the acceptance letter is created and distributed to stakeholders. Upon the

return of the signed letter of acceptance the membership profile will be activated. If the signed acceptance

letter is not returned within 30 days from date of generation, it is terminated.

7. If no underwriting was identified on the new profile, the new membership is immediately activated, and the

certificate of membership, welcome letter, as well as the membership card is sent automatically.

For queries and progress contact [email protected] or log on to the Bestmed broker portal.

Our

benefits and programmes


In an

emergency?

Contact ER24

Step 1:

Call 084 124 or 010 205 3000 The despatcher will require:

• Your name.

• The nature of the emergency.

• The address of the emergency. Please ensure that the address is clearly

stated including the province, suburb, street name and number, building/

complex name and number. If possible please provide the nearest landmark.

• Please inform security, if required, as to where the emergency is.

• Your contact number where you can be reached.

Step 2:

• You will receive an SMS verifying the address of the emergency.

• The SMS will also provide a reference number for any future communication.

• Please check the SMS to confirm that the address has been correctly

captured.

What happens if I don’t use ER24 in an emergency?If you or a family member make voluntary use of a service other than ER24 for

transportation, you will be liable for the cost of the service.

When you require assistance, follow these steps:

Step 3:

• ER24 will dispatch a vehicle to the scene of

the emergency.

• It may be an ER24 vehicle or a service

provider contracted to ER24, if there is no

ER24 vehicle immediately available in the

nearby vicinity.

Step 4:

• Please inform the ambulance crew of a

nearby Bestmed Designated Service Provider

(DSP) if possible. Depending on the nature of

your emergency, the ambulance may be

obliged to take you to the nearest medical

facility.


In an emergency? Contact ER24

What does this benefit cover?• Medical transportation in the event of an emergency by road or air ambulance, whichever is considered

medically necessary by ER24, to the nearest appropriate medical facility.

• An upgrade in care from a medical facility, which does not have the appropriate care available to

manage the patient’s medical condition, to a facility that is capable of managing the condition using

the most appropriate ambulance transportation (road or air) as determined by ER24.

• One way transportation per hospital admission from one medical facility to another for the purpose of

a diagnostic test for example a CT scan.

• Transportation from a registered medical facility to an oncology treatment centre. Up to a maximum

of 3 times per admission.

• Transfer from a registered medical facility to a registered rehabilitation/ step down facility, where

there is authorisation in place from Bestmed.

What is not covered by this benefit? • Any ambulance transportation for conditions that are not a result of a medical emergency, where the

service is used purely as a means of transportation. This includes transportation when a member is

pregnant and is in normal term labour with no complications during the pregnancy.

• Any transportation to a home address or an old age home with no authorisation from Bestmed.

• Any transportation to a doctor’s room for an appointment or for the purpose of an X-ray where no

medical emergency exists, or for any procedure that could be done in the current medical facility.

• Any transportation from a home address or step down for any booked procedures or doctor’s visit

including dialysis or oncology treatment.

• Any transportation for any other reason other than that the referring medical facility is unable to

manage the patient.


Travelling

overseas?

We’ve got you

covered!

Did you know that you are covered for up to R10 million rand for international travel for a maximum of 90 days per journey?

This policy is underwritten by Bryte Insurance and managed by ER24. It’s very important that you register your travel dates

at least 1 week before you travel by either by calling Bryte Insurance on 0860 329 329 or ER24 on 010 205 3100. You can

also register your travel by sending an e-mail to [email protected] and providing them with the following information:

Your Bestmed membership number

The names and ID / passport details of all travellers

The destination countries

The dates of travel

Contact details including an e-mail address and telephone number whilst travelling

Information regarding activities or sports that you will be participating in that could be considered as hazardous.

In the case of an emergency whilst travelling, please contact Bryte Travel Assist on +1 416 642 2910 or [email protected].

Alternatively you may contact ER24 on +27 10 205 3100 and they will put you through to BryteTravel Assist.

The Council for Medical Schemes (CMS) published Circular 45 of 2018: International Travel Benefit stating that the below-men-

tioned non-healthcare benefits cannot be included in medical scheme benefits and therefore a member will need

to take out additional insurance to cover the below.

Repatriation of remains

Compassionate emergency visits

Refund of emergency telephone calls

For retrospective claims, you can request an international claim form by sending an e-mail to [email protected] or by

calling 0860 222 446. Please note that should you have paid international medical costs and need to claim them back, you

will need to provide the following:

The international travel policy documentation

Airline tickets showing the dates of travel

Copies of your passports

Copies of all relevant invoices as well as proof of payment.

Bryte Travel Assist may request further medical information from your treating practitioner in South Africa, including medical

reports relating to any pre-existing medical condition or consultations.


What you need

to know about

medicine!

At Bestmed we offer cover for a specified list of Chronic Disease List (CDL), Prescribed Minimum Benefit (PMB) conditions and non-CDL. The Scheme offers cover on all options according to the below:

26 CDL conditionsDiagnosis and medical management covered from Scheme benefits.

16 PMB conditionsDiagnosis, medical management and medicines are covered from Scheme benefits.

28 Non-CDL conditions The non-CDL conditions are additional conditions which may be covered by the Scheme depending on the chosen

benefit option. It is NOT compulsory for the Scheme to fund treatment and medicine for these conditions.

Approved non-CDL, CDL and PMB chronic medicine is paid from the chronic medicine limit first. Thereafter,

approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk

Approved CDL and PMB chronic medicine is not subject to annual financial limits.

Non-CDL chronic medicine is subject to annual financial limits.

How do I apply for chronic medicine? For all initial applications, the treating provider must complete the chronic application form and send it to

[email protected] or fax (012) 472 6760.


What you need to know about medicine!

Take note: • Motivations and reports by relevant medical practitioners may be requested by the Scheme.

*Authorisation for CDL, PMB and non-CDL chronic medicine is subject to clinical funding guidelines

and protocols, formularies and Designated Service Providers (DSPs) where applicable.

How often do I need to renew my chronic prescription?According to the law, doctors may not issue a repeat prescription for longer than a 6 month period. Repeat

prescriptions need to be updated every six months for dispensing purposes only. A prescription is only valid for

6 months but chronic authorisation can be granted for a longer time period. Bestmed does not require a

prescription every 6 months, unless requested.

Why is my chronic medicine application declined?Your application may be declined due to the following reasons:

The condition applied for is not covered by the member’s chosen option.

The prescribed medicine does not qualify for chronic benefits (For example, vitamins may only be

covered from the vested savings depending on the option. Vitamins are not classified as chronic medicine.)

Additional supporting information may be required (For example, pathology/radiology results).

Some conditions and/or medicines are only covered if we receive all the information required as per

our funding guidelines (For example, treatment and/or medical history)

Treatment does not meet the funding guidelines for the chosen medicine and/or condition.

If your chronic application is declined, you will receive a letter that explains the reasons.

How do I update my chronic medicine authorisation?We need a copy of the most recent prescription which includes all the changes to the medicine, in order to update the

chronic medicine authorisation.

Additional supporting information may also be required depending on the condition or medicine prescribed:

Cholesterol – renewal or changes in medicine/dose requires a prescription and latest lipogram.

Psychiatric – renewal requires a prescription from a psychiatrist or a family practitioner (FP) if the dosage and

medicine remains the same. A FP can renew the prescription for a period of 24 months if the medicine and dosage

remains the same.

Osteoporosis – renewal requires a prescription and latest DEXA scan.

You can send the information above to:

Fax 012 472 6760

E-mail [email protected]

Or via the Bestmed App.



How are CDL and PMB conditions covered?For each CDL and PMB condition that is approved, there is a basic treatment plan. The treatment plan is dependent on

the condition and can include consultations, pathology and/or radiology. For each approved treatment there is a

maximum limit per year at specific intervals.

The services in the treatment plan will pay from the applicable day-to-day limit first. Once the limit is depleted, claims

will continue to be paid from Scheme risk, up to the maximum quantity specified in the treatment plan. The treatment

plan allocations are reset in January every year.

What non-CDL conditions are covered by Bestmed?The non-CDL conditions that are covered by the Scheme depend on the chosen benefit option. It is NOT compulsory for

the Scheme to fund the treatment of these conditions.

BEAT1 BEAT2 BEAT3 BEAT4 PACE1 PACE2 PACE3 PACE4 PULSE1 PULSE2

NON-CDLnon-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 Major depression √ √ √ √ √ √

non-CDL 8 Obsessive compulsive disorder

√ √ √ √ √

non-CDL 9 Osteoporosis √ √ √ √

non-CDL 10 Psoriasis √ √ √ √

non-CDL 11 Urinary incontinence √ √ √ √

non-CDL 12 Paget’s disease √ √ √ √

non-CDL 13 Gastro-oesophageal reflux disease (GORD)

√ √ √ √ √

non-CDL 14 Ankylosing spondylitis

√ √ √

non-CDL 15 Hypopituitarism √

non-CDL 16 Osteoarthritis √ √ √ √

non-CDL 17 Alzheimer's disease √ √ √ √

non-CDL 18 Collagen diseases √ √ √

non-CDL 19 Dermatomyositis √ √ √

non-CDL 20 Motor neuron disease √

non-CDL 21 Neuropathy √ √

non-CDL 22 Polyarteritis nodosa √

non-CDL 23 Scleroderma √

non-CDL 24 Sjogren's disease √

non-CDL 25 Trigeminal neuralgia √

non-CDL 26 Psoriatic arthritis √

non-CDL 27 Blepharospasm √

non-CDL 28 Dystonia √



What are formularies and how do they affect co-payments on chronic medicine?A formulary is a pre–determined list of medicines that will be covered for CDL, PMB and non–CDL conditions. These lists vary from

option to option.

When do co-payments apply for chronic medicine?• If medicine is prescribed/selected for the treatment of a CDL, PMB or non–CDL condition and is not listed on the formulary.

• If the prescribed/selected medicine costs more than the Mediscor Reference Price (MRP). If the pharmacy charges more

than the MRP, a co-payment will apply. To avoid co-payments, rather ask for a generic alternative.

• A formulary co-payment on non-CDL conditions is applicable depending on the chosen plan option.

Please note that according to the Council for Medical Schemes (CMS) co-payments may not be deducted from your

savings account or reimbursed to you.

The co–payment percentage varies according to the different benefit options. The table below highlights the different

co–payments applicable per Scheme option for the CDL, PMB and non–CDL conditions:

Benefit

Non-formulary

co-payment for CDL

and PMB conditions

Fomulary co-

payment for non-

CDL conditions

Non-formulary

co-payment for

non-CDL conditions

Beat1 / Beat1 N

40%

No

benefit

No

benefit

Beat4

30%

10%

25%

Beat2 / Beat2 N

40%

No

benefit

No

benefit

Pace2

30%

10%

25%

Pace4

20%

10%

15%

Beat3 / Beat3 N

40%

20%

35%

Pace1

35%

10%

30%

Pace3

25%

10%

20%

Pulse1

40%

No

benefit

No

benefit

Pulse2

25%

10%

20%

Does Bestmed have a pharmacy network? Yes we do have a pharmacy network and they dispense medicine at a Bestmed negotiated rate.

Choosing a pharmacy that isn’t on our network could mean higher co-payments which could potentially

deplete your benefits sooner.

Our pharmacy network includes:

Courier Pharmacies (these are pharmacies that deliver to you)

Dis-Chem courier

Script Wise (S Buys courier)

Pharmacy Direct and

Clicks courier



Corporate retail pharmacies (these are pharmacies that you are able to visit)

MediRite (in Checkers and Shoprite stores)

Dis-Chem

Pick 'n Pay Pharmacy

Clicks Retail

Independent retail pharmacies

The participating independent retail pharmacies are listed on the Bestmed website. Members and providers

can log on to the Bestmed website or the Bestmed App to view the pharmacies on the network.

We also have designated pharmacy networks in: Lesotho

Namibia

Swazi land

What is the Over-the-Counter (OTC) benefit on the various options?OTC medicine is available for self-diagnosis and treatment, for example, if you have a cold and you need to buy medicine

without seeing your doctor. The benefits on the different plan options are as follows:

No benefit

Savings account

Savings account

* Member has a choice of: 1. R650 OTC limit. This is the default OTC choice. OR

2. Access to full savings for OTC purchases (after R650 limit) = self-payment gap accumulation. Members wishing to choose this second option are welcome to contact Bestmed.

Savings account

* Limited to R368 per family. Subject to prefered provider network pharmacy.

* Limited to R579 per family. Subject to prefered provider network pharmacy.

Beat1/Beat1 N

Beat2/Beat2 N

Beat3/Beat3 N

Beat4

Pace1

Pace2 Pace3

Pace4

Pulse1

Pulse2

* Includes suncreen, vitamins and minerals with nappi codes on Scheme formulary. Subject to the available savings or benefit limit.



What are the medicine exclusions not covered by Bestmed?1. Preparation for the treatment of obesity, including dietary supplements.

2. Patent and household remedies, except for those that are prescribed in the treatment of certain PMB conditions and are available in the state sector.

3. Nutritional supplements (including patent and baby foods), except for those that are prescribed in the treatment of certain PMB conditions and are available in the state sector.

4. Medicines used specifically to treat infertility, except for those that are prescribed in the treatment of certain PMB conditions and are available in the state sector.

5. Aphrodisiacs.

6. Sun-screening agents (medicated or otherwise) on the Beat1 and Beat1 Network options.

7. All soaps and shampoos (medicated or otherwise).

8. Cosmetic substances.

9. Anti-habit substances.

10. Anabolic steroids.

11. Unless specifically provided for on the benefit options; tonics, stimulants, biological substances, vitamins, minerals and vitamin/ mineral combinations are excluded, except for those that are prescribed in the treatment of certain PMB conditions and are available in the state sector.

12. Unregistered medicines will not be considered for benefits until such time that it is registered by the Medicines Control Council (MCC).

13. Unregistered indications or “off label” use of medicines will not be considered for benefits except for those that are prescribed in the treatment of certain PMB conditions and are available in the state sector.

14. Haematinics.

15. Biological and Biotechnological substances.

16. Stimulant laxatives.


Dental

benefits

How do I find a dentist on the network? - Go to www.bestmed.co.za

- Click on ‘search for a service provider’

- Enter your membership number and password to login

- Select ‘dentist’ in the provider section

- Filter your search further by including your area

How do I submit claims?You can submit your claims to [email protected]

How is dentistry covered on each plan option?

PLAN OPTION

Beat1

Beat2

Beat3

Beat4

Pace1

Pace2

Pace3

Pace4

Pulse1

Pulse2

BENEFIT

Not applicable

Savings

Savings

Savings first, then from dental day-to-day benefits




Dental day-to-day benefits

Basic primary care, subject to Bestmed protocols

Dental day-to-day benefits


Dental benefits

Which dental benefits require pre-authorisation?The in-hospital dental procedures require pre-authorisation.

Pre-approval is also required for the below:

• Orthodontic treatment

• Conscious sedation

To obtain pre-approval please send your quotes to [email protected]

How do I get pre-authorisation for dental procedures?For in-hospital pre-authorisation call 0800 220 106 or send an e-mail to [email protected]

Where can I find more information on my available benefits for specialised dental procedures?You can visit our website www.bestmed.co.za or consult your benefit guide.

Description of service

General full-mouth examination by a general dentist (incl. gloves and use of sterile equipment for the visit)

Full-mouth intra-oral radiographs

Intra-oral radiograph

Scaling and/or polishing

Fluoride treatment

Fissure sealing

Space maintainers

Age

12 years and older

12 years and below

All ages

All ages

All ages

All ages

Up to and including 21 years.

During primary and mixed denture stage

Frequency

Once a year

Twice a year

Once every 36 months

2 photos per year

Twice a year

Twice a year

In accordance with accepted protocols

Once per space

Beat

√

*Only available on Beat2, Beat3 & Beat4

√

√

√

√

√

√

Pace

√

√

√

√

√

√

√

√

Pulse

X

X

X

X

X

X

X

X

*Subject to pre-authorisation, clinical protocols and funding guidelines

Our preventative dental benefit

Note: The Pulse range offers preventative services under the basic and specialised dentistry benefit


How does Bestmed cover optical benefits? Bestmed provides optometry benefits through the Preferred Provider Negotiators (PPN) network. PPN manages the

screening and administration of optometry claims, as well as queries for members on their chosen plan options. PPN is

one of the largest optical networks in the country with more than 2700 registered providers.

Members and beneficiaries on all plan options, excluding Beat1 and Beat2 have access to bi-annual optometry benefits.

Members on Beat2 have access to optometry benefits through their savings accounts.

Your optical benefits explained Each member and their dependant has access to optometry benefits within a two-year benefit cycle, subject to their last

claiming date. Members can claim for spectacles or contact lenses during the two-year benefit cycle, but not for both.

You are entitled to one comprehensive consultation (including a refraction, tonometry and visual field screening) and:

• A frame and/or lens enhancement to the value per option and one set of standard clear lenses; or

• Contact lenses to the benefit value per option.

Always check the value of your optical benefits per plan option to avoid co-payments.

Consultations at PPN providers for clear single vision, bifocal or base multifocal lenses are covered fully, excluding

Pulse1 as base multifocal lenses are covered up to the bifocal limit.

Please note that the Scheme covers optometry benefits according to the PPN agreed network tariff, and the use of a

non-PPN provider may result in additional costs for which the member is liable.

2nd Benefit warranty

PPN now offers members a second benefit warranty for lost, damaged or broken spectacles within the two-year

benefit cycle from the date of service. The second benefit warranty is only available on Beat3/Beat3 network,

Beat4, Pace1 to Pace4, Pulse1 and Pulse2 options.

Optical benefits:

See more with

Bestmed!


Benefit

Beneficiary

sub-limit

Beat3 / Network

R 1 510

Beat4

R 1 510

Pace2

R 1 510

Pace4

R 1 510

Pace1

R 1 510

Pace3

R1 510

Pulse1

R600

Pulse2

R1 510

IN NETWORK

WITH EITHER

OR

Spectacles:

Contact Lenses:

Benefit Cycle

Consultation

Frames/Lens

enhancements

Lenses

PPN Frame/Lens

enhancements

to the value of

R237 once

every 24

months at a PPN

provider only

PPN Frame/Lens

enhancements

to the value of

R868 once

every 24

months at a PPN

provider

Each beneficiary is entitled to either Spectacles or Contact Lenses in a 24 month benefit cycle

100% of cost for a Composite Consultation inclusive of the refraction, a glaucoma screening and visual field

screening

PPN Frame/Lens enhancements to the value of R868 once every 24 months

at a PPN provider

100% towards the costs of standard lenses at network rate for either one pair of

single vision lenses OR one pair of bifocal lenses OR one pair of multifocal lenses.

(Pulse 1 - Base Multifocal lenses covered up to the value of clear bifocal lenses at a PPN provider)

What information do I need to confirm my benefits? • Member/dependant full name

• Surname

• Identity number

• Date of birth

• Medical scheme number

• Broker code

To confirm your optical benefit, contact the PPN call centre at 0861 103 529 or visit the PPN website at www.ppn.co.za.

Your PPN provider will submit claims via the PPN web-based system “Optimum” which will be processed within 48 hours.

Paper based claims may also be submitted to [email protected] or [email protected].

Optical benefits per plan option at a PPN provider

Optical benefits: See more with Bestmed!


Benefit

Beneficiary

sub-limit

Beat3 / Network

R 1 510

Beat 4

R 1 510

Pace2

R 1 510

Pace4

R 1 510

Pace1

R 1 510

Pace3

R 1 510

Pulse1

No benefit

Pulse2

R 1 510

NON NETWORK

WITH EITHER

OR

Spectacles:

Contact Lenses:

Benefit Cycle

Consultation

Frames/Lens

enhancements

Lenses

No Benefit

No Benefit

No Benefit

No Benefit

R579 towards

a frame/lens

enhancements

Each Beneficiary is entitled to either Spectacles or Contact Lenses in a 24

month benefit cycle

Consultation R316 per beneficiary

Each Beneficiary

is entitled to

either Spectacles

or Contact Lenses

in a 24 month

benefit cycle

R579 towards a frame/lens enhancements

Single vision lenses - R184 per lens Bifocal lenses - R410 per lens

Multifocal lenses - R747 per lens

Single vision

lenses - R184

per lens

Bifocal lenses

- R410 per

lens

Multifocal

lenses - R747

per lens

Optical benefits per plan option at a non-PPN provider

For more information, and to find a PPN network optometrist near you, logon to www.ppn.co.za.

Optical benefits: See more with Bestmed!

Consultation

R316 per

beneficiary


How does Bestmed cover radiology and ultrasounds per plan option?

Radiology

benefits

Benefit

Radiology

MRI/CT/Nuclear

MRI/CT scans

Maternity

Benefits - Ultra-

sound sonar

PET scans

Beat1 / Beat1 N

X

√

√

√

X

Beat4

√

√

√

√

√

Beat2 / Beat2 N

√

√

√

√

X

Pace2

√

√

√

√

√

Pace4

√

√

√

√

√

Beat3 / Beat3 N

√

√

√

√

X

Pace1

√

√

√

√

√

Pace3

√

√

√

√

√

Pulse1

√

X

√

√

X

Pulse2

√

√

√

√

√

* √ Applicable X Not applicable

Please note: All in-hospital procedures are subject to pre-authorisation.

Is pre-authorisation required for MRI and CT scans?Yes, you will need to obtain pre-authorisation to access this benefit. In the event of an emergency, authorisation will need to be obtained

on the 1st (first) working day, post-admission to a hospital by the Scheme or its proxy.

For pre-authorisation contact [email protected] or call 0800 22 0106


Oncology

programme

Do all Bestmed plan options cover Oncology? Yes, all Bestmed members have access to our Oncology programme.

OPTION

Bea1 & N

Beat2 & N

Beat3 & N

Beat4

Pace1

Pace2

Pace3

Pace4

Pulse1

Pulse2

EXTENDED

√

√

SPECIALISED RADIOLOGY

R5 089/family/year

R5 089/family/year

R10 688/family/year

R16 172family/year

R13 911/family/year

3x CT, MRI, Nuclear1x PET per beneficiary subject to

pre-authorisation


pre-authorisation


pre-authorisation

-


pre-authorisation

BIOLOGICAL/HIGH COST LIMIT

PMBs only as per funding protocol.

PMBs only as per funding protocol




R158 221

R316 652

R468 645


R149 279

STANDARD (PMB)

√

√

√

√

√

√

√

√

√

√

How do I register? To register, send the following information to [email protected]:

The histology report containing the ICD-10 codes.

The Oncology treatment plan with set out clinical details and requested treatment and tariffs.


What benefits do I get access to post - diagnosis?• Access to benefits and services that form part of the treatment protocol

• Oncology treatment that includes chemotherapy, radiotherapy, certain pathology and various consultations

• Supportive medicines within the Bestmed oncology formulary

• If the prescribed treatment falls outside of prescribed protocols, a clinical motivation can be submitted by the

Oncologist for consideration by the clinical committee.

Frequently asked questions Oncology is a branch of medicine that deals with the diagnosis and treatment of cancer.

A medical professional who practices oncology is an oncologist.

There are two types of cancer:

1. Cancer that affects non-solid organs and systems

2 Cancer of solid organs

Cancer of solid organs qualifies as a prescribed minimum benefit (PMB) only if it is “treatable”. Thus, not all cancers of non-solid organs necessarily meet the requirements for PMB’s. However, there are various cancers of non-solid organs and systems that qualify as PMB conditions - whether they are treatable or not. For example, acute leukemia, lymphomas, multiple myeloma and chronic leukemia all qualify for PMB.

“Treatable” cancer is defined as cancers that affect solid organs where:

• They affect the organ of origin and have not spread to adjacent organs

• There is no evidence of spread to other organs that are far from the organ where the cancer has started

• They have not brought about incurable damage to the organ in which they originated, or in another life- supporting organ

• Or, if none of the above apply, there is scientific evidence that more than 10% of people with a similar cancer, in the same state, survive on treatment for at least 5 years.

Please note: • All services are subject to pre-authorisation and clinical protocols

• Only the benefits stipulated by the Scheme will be funded

• Services must fall within Bestmed's protocols, Scheme rules and funding guidelines

For more information contact: Oncology Care programme

Tel: +27 (0) 12 472 6254/6234

Fax: +27 (0) 12 472 6770

E-mail: [email protected]

Oncology programme


HIV/Aids

programme

What does the HIV/AIDS programme offer? The Bestmed HIV/AIDS disease management programme is designed to help members and their dependants living with

HIV/AIDS to remain healthy and to live a productive life.

Members registered on the HIV programme receive a treatment plan and the most appropriate care from medical experts.

Who is LifeSense?LifeSense is the managed care organisation, that has been appointed by Bestmed to do disease management for

Bestmed members registered on the HIV/AIDS disease management programme.

Do I have to register for the HIV/AIDS Programme? All members who want to join the HIV/AIDS management programme need to register with LifeSense in order to

gain access to this benefit

What does this programme cover?

The exact benefits provided by the HIV/AIDS disease management programme are determined by the stage of

infection and the advised treatment.

Benefits include:

• The cost of clinically appropriate pathology tests

• Consultations by the treating doctor

• Prescribed medicine according to formulary

• Hospital treatment subject to pre-authorisation and DSPs/Network Hospitals

Note: Treatment plans and funding guidelines apply.

Cover is also provided for mother-to-child transmission in pregnancy and post-exposure prophylaxis. Members also

receive personal advice from qualified healthcare professionals, as well as access to additional healthcare benefits.


How do I register?To register, simply phone the LifeSense helpline on 086 050 6080. LifeSense will send you an application form, which has to be completed by the relevant dependant and the treating doctor.

• The doctor/dependant can then submit the form to LifeSense, together with the blood results.

• LifeSense will approve a treatment plan for you, based on the information received.

What happens once I have registered?A LifeSense disease management case manager will keep in contact with you going forward. The case manager will

provide you with assistance, support, and guidance for the correct use of medicine.

Bestmed Designated Service Providers (DSPs) are available on this programme. The DSPs include medical practitioners,

pharmacy networks and hospitals.

Will I receive counselling and support services?Yes, LifeSense has qualified psychologists and highly-skilled counsellors available for you.

Where can I get my medicine?- You have to choose a DSP pharmacy, either a courier or retail pharmacy to dispense your anti-retroviral therapy (ART).

- You need to communicate your choice to LifeSense so that they provide the pharmacy with the correct documentation and information.

The list of pharmacies is available below.

General contact details

LIFESENSE CONTACT DETAILS

Tel 086 050 6080

Fax 086 080 4960

Email [email protected]

HIV/AIDS DSP Pharmacies:

Pharmacy contact details

Clicks Direct Medicine (Courier Pharmacy)

Contact centre 086 144 4405

Fax 086 144 4414


Emergency contact 010 210 3364 or 010 210 3330

Clicks Retail Pharmacies


Fax 021 460 6752


Website https://clicks.co.za/pharmacyclinicservicespharmacylocator

Dis-Chem Direct (Previously Optipharm Courier Pharmacy)


Fax 086 641 8311


Emergency contact 083 564 9978

Dis-Chem Retail Pharmacies


Website www.dischem.co.za/storelocator


HIV/Aids programme


Back and neck

programme

What is the back and neck programme? The programme is intended to be a preventative programme in lieu of neck and/or back surgery. Documentation Based

Care (DBC) and Workability are providers for Bestmed’s Back and neck treatment programme.

The back and neck programme is completely evidence and outcomes based with a success rate in excess of 85%.

The principles applied are those of analysing, correcting and maintaining correct body posture as well as stabilisation

of the spine.

How do I get access to the programme?

Bestmed will refer you and/or you need to schedule an appointment at your nearest Bestmed designated DBC/

Workability clinic.

Once you have attended the first assessment session. The doctor will decide if you are a suitable candidate for

the programme. The clinic will submit an application to Bestmed on your behalf to obtain authorisation for access to

the programme.

A member needs to visit a DBC/Workability facility and undergo an initial assessment in order for the clinic to determine

if the member is a suitable candidate. The first assessment will be covered by the Scheme if the member qualifies for

the programme. If the member doesn’t qualify, the amount of the first assessment will either be payable from available

day to day benefits/savings or from the member’s own pocket.

There are also instances where the Scheme could refer a member, scheduled for surgery, to visit such a clinic. These

referrals are covered by Bestmed.

Please keep in mind that a full clinical history, including the latest X–rays and other reports may be required. These may

be used by the staff at the facility when visiting the facility for an assessment. Once the assessment report has been

evaluated and discussed, a rehabilitation treatment programme may be suggested. Bestmed will confirm the services

that will be reimbursed and for which duration. After obtaining pre–authorisation from the Scheme, an appointment will

be made by the service provider for the programme to start.

Who can access the benefits?

All qualifying Bestmed members have access to the benefit.

For more information please e-mail [email protected] or call (012) 472 6249/6235


Maternity

care

Registration: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.

How to register:Contact [email protected] or phone 012 472 6243 to provide us with the following:

Contact details (postal/delivery addresses)

Medical scheme number

Expected delivery date in the e-mail.

After registration you will receive: A welcome pack with an informative book about the stages of your pregnancy.

Discount vouchers.

A beautiful baby bag. (Sent by month 5 of your pregnancy. You will receive an SMS).

Various baby items.

Access to a 24-hour medical advice line.

Different benefits through each phase of your pregnancy.

Pregnant members and their dependants have access to the Bestmed Maternity Care programme. The programme provides comprehensive information, services and was designed with the needs of expectant parents, and their support network in mind.

We aim to give you support, education and advice through all stages of your pregnancy, from the discovery to the after birth period.


Maternity care

Phases of the Bestmed Maternity Care programme:

Pregnancy phase 1 (week 1 to 11)

Although it is very early in your pregnancy, it is a very important period.

A lot happens during these first three months. The fertilised egg rapidly

divides into layers of cells and implants in the wall of your womb where it

carries on growing. These layers of cells become an embryo, which is what

the baby is called at this stage. During this first trimester, your baby grows

faster than at any other time. By six weeks, a heartbeat can usually be

heard.


The second trimester is the middle three months of your pregnancy,

roughly months four, five and six. As you go through the second trimester,

you will start feeling and looking more pregnant and you may have more

energy than you did in the first trimester and later you'll start to feel your

baby moving. By this time your pregnancy should have been registered at

Bestmed. We will monitor your pregnancy and identify possible high-risk

pregnancies.


This is the last three months of your pregnancy. Feelings at this stage of

pregnancy tend to go from tiredness and worry to excitement

about the baby. In this phase we will continue to monitor high-risk

pregnancies closely and you will start to prepare for the delivery and all

decisions regarding it.

Phase 4 (Birth)

At this stage expectant moms have the uncertainty of when labour will

start or how they will know what to do. You might be feeling worried about

going out, making plans or being alone in case you go in to labour. However,

in most cases labour starts slowly with contractions very widely spaced,

leaving you plenty of time to get home. This is especially true if it’s your

first child, so don’t feel like you have to stay in the house.

You might also be worried about knowing when you should go into hospital,

especially if it’s not close by. When you are having a contraction every five

minutes that lasts 30+ seconds, call your midwife, birth centre or hospital

labour ward if you are giving birth there. If you have chosen a home birth,

the midwife will come to you. Around your due date, our maternity care

team will call you to check up on your progress and/or whether baby has

arrived.

Phase 5 (Baby Care)

You will be contacted again post birth to check up on both you and baby's

wellbeing. We will also connect you with the necessary service providers to

assist you with any problems that you may experience.

During these stages we will support you with:

Access to a 24-hour medical advice line.

Pregnancy wellness checks and interventions at a

dietician and biokineticist, provided that you are

registered on the Tempo programme.

Weekly e-mails with helpful tips about your

pregnancy, your baby’s development and how to

deal with unpleasant pregnancy symptoms.

Dads will receive e-mails too to inform them about

their baby’s development and mom’s progress.

Education/Information website

If you miscarry, we will provide you with access

to a nurse help-line, and psychologists or

counselling if necessary.

Separate monitoring programme for high-risk

patients.

During these stages we will support you with: Hospital authorisation.

Personal e-mails with helpful tips and how to deal

with symptoms.

Separate monitoring programme for high-risk

patients.

Wellness interventions – assessments and follow-up

consultations at biokineticists and dieticians,

provided that you are registered on the Tempo

programme.


Use the Bestmed

provider network

and get more

value!

• 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.

• Fewer co-payments depending on benefits available.

• A longer lasting medical savings account.

• A dedicated provider consultant service is available to the network providers.

Visit www.bestmed.co.za to view our detailed network list.

Use the Designated Service Provider (DSP) network for

Prescribed Minimum Benefit (PMBs)

This specialist network includes all the major specialist disciplines and includes over 2 400 specialists who are located

across the country, with room near to or inside many of the general private hospitals. This network continues to grow

with more and more providers joining every month.

Members are required to use a specialist on the DSP network for services (including other PMB conditions). These

services will be charged and paid at the agreed DSP rate. If a member voluntarily chooses not to use a specialist

from the DSP network, the Scheme will only pay up to the Scheme tariff, and any charges above this will be on

the member’s own account.


Underwriting concession for new members at existing groups

Bestmed is granting a once-off group concession for your existing corporate clients to join without risk underwriting.

From 1 October to 31 December 2019, a voluntary window period will be permitted to any existing active employee who submits a

completed and signed application form during the year-end period. No waiting period will be imposed on employees joining Bestmed

during this period, including those interchanging from a different medical scheme to Bestmed.

The window period will also be valid in the case of current Bestmed members who apply to have their immediate dependants registered

with the Scheme. Immediate dependants include spouses/partners as well as children, as defined in the Bestmed Rules. Extended family

members will, however, be subject to full underwriting.

Normal risk underwriting in accordance with Bestmed’s Rules will be applicable after the concession period as stipulated in our Risk

Underwriting Policy.

We will, however, evaluate every application made after 90 days from the date of permanent appointment, marriage or divorce for a final

risk underwriting decision.

Please communicate and facilitate the above with your clients. We trust we will grow our businesses together over this period.

Should you have any questions or require assistance, please speak to your broker consultant.


Contraceptive

list

All females of child-bearing age qualify for female contraceptives.

Benefits are subject to the following:

Mediscor Reference Price (MRP)

This price represents the reasonable price in the market for a particular group of generic equivalent medicines which is reviewed and

updated regularly. MRP sets a maximum reimbursable price for a list of generically similar medicines with a cost lower than that of

the original medicine. There may be instances where a generic alternative costs more than the set MRP. If you opt to use the original

medicine and a generic alternative is available, or you use a medicine that costs more than the MRP, you will have to pay the difference

between the price of the chosen medicine and that of MRP.

This list is subject to change without notice.

This benefit is available on all Bestmed options.

There is an annual limit per beneficiary per year.

Name Nappi Code

Adco-fem 35 tabs 706126001

Biphasil tab 825808006

Cilest 702542003

Claro 35 tabs 707378001

Copper t premium pack 600290001

Copper-t 380a 438254006

Dalcept c contraceptive device 664354007

Dalcept c contraceptive device 664362003

Depo-provera 150mg/mL 1mL 718440005

Device contraceptive cu.375 527056002

Device cuprocept ccl 549612003

Device intrauterine tricept la 549607003


Diane-35 tabs 825859018

Diva-35 tabs 707875001

Escapelle 1.5Mg tabs 710109001

Evra patches 704091001

Famynor tabs 720417001

Femodene ed tabs 825905001

Femodene ed tabs 825905028

Ginette tabs 897214005

Hy-an 30mcg tabs 720418001

Implanon nxt implant 718619001

Intra uterine contraceptive iud 152454001








Intra uterine device cu375 131904001

Intra-uterine copper device cu375 137456002

Kyleena 19.5mg iud 3000026001

Levette 0.15Mg/0.03Mg tabs 721606001

Logynon ed tabs 825956005

Marvelon tabs 825964008

Medilevo 1.5Mg tabs 3000062001

Melodene tabs 842893008

Mercilon tabs 825972019

Micro-novum 0.35Mg tabs 825999006

Microval tabs 826006019

Minerva tabs 897311004

Minesse tabs 879576006

Minulette tabs 826014003

Mirelle tabs 880418001

Mirena kit 852252005

Nordette tabs 826030009

Nordiol tabs 826049001

Norlevo tabs 880612002

Nova t 380 iud 530671003

Novynette tabs 723085001

Nur-isterate 200mg/mL inj 748552006

Nur-isterate 200mg/mL inj 748552014

Oralcon tabs 720419001

Ovral tabs 826138004


Petogen fsk 150mg/mL vial 780642009

Plan b 0.75Mg tabs 721167001

Qlaira tabs 716676001

Ruby tabs 716207001

Tricilest 847380009

Trigestrel tabs 720420001

Trinovum tab 826073018

Triodene ed tabs 825816009

Triphasil tabs 825832004

Vonel 0.75Mg tabs 723165001

Yasmin tabs 700089001

Yasmin plus tabs 723736001

Yaz tabs 712856001

Yaz plus tabs 723730001

Zoely 2.5Mg/1.5Mg tabs 720904001


Vaccineschedule

(As per the Department

of Health)

Paediatric Vaccines (excluding Beat1 and Beat1N)

Age Groups Indicated for Name Description Nappi Code

0 to 2 months

OPV Merieux 10 Dose

Bivalent Oral Polio Meriuex

OPV Merieux 10 Dose plastic tub

OPV Meriuex 20 Dose Vaccine

Polio TD 0.5ml

Polioral 10 Dose Trivalent

Imovax Polio Vaccine

Polio

823678008

722017001

841307016

823686019

703335001

812331028

708854001

0 to 2 months BCG Intradermal Infant 20 Tuberculosis 872962016

0 to 5 years (Included on Beat1 and

Beat1N)

Prevenar 13 28mcg/0.5ml Prefill

Prevenar 16mcg/0.5ml Prefill Syringe

Synflorix Vaccine

Pneumococcus

715858001

705032001

714999001

1 to 4 monthsRotarix Liquid Oral Vaccine

Rotateq 2ml VaccineRotavirus

714133001

710935001


1 to 6 months

Engerix-B Paed Monodose

Euvax B Vial 20mcg/ml

Euvax B Vial 20mcg/ml

Heberbiovac HB Single Dose 0.5ml

Heberbiovac HB Single Dose 1ml

Hepaccine-B Paed Single Dose

Hepatitis B

700356001

713048002

715349001

701658001

701659001

873179005

1 to 24 months

Acatcel-Pasteur 0.5ml

Combacthib Single Dose 0.5ml

Tritanrix-hb 0.5ml Single dose

Diptheria

Haemophilus Influenzae Type B

Pertussis

Tetanus

703226003

834203006

700768001

2 to 6 monthsDTP-Merieux Single Dose Syringe

Infanrix Pre-filled Syringe 0.5ml

Pertussis

Tetanus

825158001

703994001

1 to 18 months

Hexaxim Pre-filled Syringe

Pentaxim Prefilled Syringe

Infanrix Hexa Vaccine

Diptheria

Haemophilus Influenzae Type B

Hepatitis B

Pertussis

Polio

Tetanus

719637001

707522001

707285001

2 months to 5 yearsACT-HIB Flu Single Dose 0.5ml

Hiberix Single Dose 0.5ml + SalineHaemophilus Influenzae Type B

813206006

700767001

6 to 12 months

Rouvax Single Dose Syringe

Measles vaccine 0.5ml

Measbio Multi-Dose Powder Vial

Measles

825522005

720384001

722290001

9 months to 55 years Menactra Vaccine 0.5ml Vial Meningitis 720708001

12 to 18 monthsAvaxim Prefilled Syringe 80 0.5ml

Havrix Junior Single Dose 0.5mlHepatitis A

700513001

703448001

12 months to 6 yearsVarilrix Vial

Onvara 1350 PFU/VialChickenpox

892939001

723131001

12 months to 6 years

Morupar Single Dose

Omzyta Vaccine Powder

Priorix Single Dose 0.5ml Prefill

Measles, mumps & rubella 0.2ml

Trimovax 0.5ml

Measles

Mumps

Rubella

879452005

724016001

700772001

720383001

792004019


12 months to 6 years Priorix Tetra Vial

Chickenpox

Measles

Mumps

Rubella

716550001

1 year and olderTwinrix Vaccine

Twinrix junior vialHepatitis A and B

706829001

892944004

2 to 12 yearsTypherix Pre-Filled Syringe Single

Typhim VI 0.5ml PrefilledTyphoid Fever

703442001

822442019

2 years and older Dukoral Vaccine Cholera 703846001

2 years and older Mencevax ACWY single dose vial Meningitis 884039002

2 years and older Vivaxim 1ml pre-filled syringeHepatitis A

Typhoid717194001

4 to 12 years

Boostrix Tetra Pre-filled Syringe

Adacel Quadra Prefill Syringe

Tetraxim Prefilled Syringe 0.5

Diptheria

Pertussis

Polio

Tetanus

716655001

713229001

711258001

Boostrix Vaccine Prefilled

Diptheria

Pertussis

Tetanus

3000689001

7 to 12 yearsDiftavax Pre-filled Single Dose

DT Vax 0.5ml Single Dose

Diptheria

Tetanus

703367001

842443002

13 years and older Diftavax pre-filled single dose

Diptheria

Tetanus

(for adults)

703367001

Age Groups Indicated for Name Description Nappi Code

No age limitEngerix B adult monodose

Heberbiovac HB single dose 1mlHepatitis B for adults

700210001

701659001

No age limit

Rabipor single dose

Sii rabivax-rabies Vaccine

Verorab syringe

Rabies

879460008

720633002

814970001

No age limit Stamaril injection Yellow fever 814989004

No age limit

Tetavax Single 0.5ml Injection

Tetagam IM 500iu/ml injection

Tetagam IM 250iu/2ml injection

Tetagam IM 2ml

Tetanus

832693006

804150028

812919009

888559004

Other Vaccines (excluding Beat1 and Beat1N)

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

HOSPITAL AUTHORISATION

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

CHRONIC MEDICINE

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

CLAIMS

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

ER24 (EMERGENCY EVACUATION)

Tel: 084 124

INTERNATIONAL TRAVEL COVER (BRYTE)

Tel: 0860 329 329 / 084 124

E-mail: [email protected] Claims: [email protected]

MATERNITY CARE

Tel: 012 472 6243E-mail: [email protected]

Contact Us

086 000 2378

[email protected]

012 472 6760

www.bestmed.co.za

@BestmedSocial

www.facebook.com/

BestmedMedicalScheme

www.linkedin.com/company/bestmed/

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 Telkom lines Hotfax: 080 020 0796 Hotmail: [email protected]

Postal: KPMG Hotpost at BNT 371 P. O. Box 14671, Sinoville, 0129, South Africa

Disclaimer: All the 2020 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 2020 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. Please note that should a dispute arise, the registered Rules, as approved by the Registrar of Medical Schemes, shall prevail.

Please visit www.bestmed.co.za for the complete liability and responsibility disclaimer for Bestmed Medical Scheme as well as the latest Scheme Rules.Bestmed Medical Scheme is a registered medical scheme (Reg. no. 1252) and an Authorised Financial Services Provider (FSP no. 44058). ©Bestmed Medical Scheme 2019.

Bestmed Medical Scheme - Aon South Africa · 2019. 10. 8. · Your Guide to Bestmed 4 Bestmed...

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