Extended Fund: Extra funds from the scheme for (mostly) out of hospital claims, over and above any savings account
Main= R15,750
Main+1= R31,500
Children Rates:
Under 24 unless registered student, then under 26
Only pay for 3 children
Note:
Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
All treatments and procedures are subject to authorisation and protocols
All benefits are listed as an indication only. Please verify with your broker and scheme
Assume scheme pays all these costs, unless otherwise stated
non-Network Specialists:
100% scheme rate
Scheme rate is set by Bestmed
network Specialists:
100% scheme rate
non-Network GPs:
100% scheme rate
network GPs:
100% scheme rate
Hospital Choice:
Long stay:: Any hospital
Day Procedure: Day network
Day Hospitals:
Day procedures at DSP: scheme rate.
If the provider is a DSP and does not work in a day hospital, the procedure will be Covered in full if it is done in an acute hospital.
Penalty for using other hospital:
non-DSP Day hospitals: R2,625 co-payment
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
* There might be other co-payments if you don't use scheme-chosen provider for some services.
* Treatment required for PMB level care is always paid by scheme, with no co-payment, if you follow the protocols. That means that these co-payments might not apply in your case! More info here
Specialised Radiology:
MRI, CT scans, isotope studies: Scheme rate
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
100% scheme rate
No limits or co-payments for PMB level care and/or for emergency
Transplants:
PMBs only
Dialysis:
Covered, in and out of hospital
Exclusions:
* Treatment required for PMB level of care is always paid by scheme, if you follow the protocols. It cannot be excluded. More info here.
* All schemes have extensive exclusions. We've tried to list the major ones here, but please consult your scheme or broker to get the full list
Alternatives to hospitals:
Alternatives to hospitalisation: 100% scheme rate
Palliative Care or at-home care, in lieu of hospitalisation: R133,182 per person
All medical aids must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
This can include consults with specialists, blood or other tests, radiology and medicine
The benefit is paid by the scheme, and not out of your savings account
If you have no day-to-day funds, you still have cover for PMBs
Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
The "day-to-day benefit" consists of a savings fund, and an "extra" fund.
Claims paid from day-to-day benefit are usually paid from savings first, then the "extra fund". Once this is finished they are paid out-of pocket, unless they are for a PMB.
You can access the free Tempo program and unlock some out of hospital benefits
GP consultations:
From day-to-day benefit
R4,808 per person and R9,744 per family
Shared with specialist benefit
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Childcare:
Ages 0-2 years: 3 baby growth and development assessments per year
Immunisations: Covered
Specialists consultations:
Shared with GP benefits, see above
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Pathology:
R3,776 per person and R7,554 per family
From day-to-day benefit
Shared with standard radiology benefit
General radiology:
Shared with pathology benefits, see above
Specialised radiology:
MRI, CT Scan, isotope studies: 2 scans per person
PET scans: 1 scan per person
Scans required for PMB level care are paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Supplementary Services: (Physio, etc)
R3,675 per person and R7,350 per family
From day-to-day benefit
General Appliances:
Out of hospital: R12,084 per family from day-to-day benefit
In-hospital: 100% scheme rate
1.1. Hearing Aids:
R33,302 per person, every 24 months, paid by scheme
1.2. Wheelchairs:
R16,342 per family every 48 months
Note:
PMBs: Prescribed Minimum Benefits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
An additional 20 non-PMB conditions are covered at 90% scheme rate, with an overall limit of R10,500 per person and R21,000 per family
If you voluntarily use medicine that is not on Bestmed's list ("formulary"), you pay a 20% co-payment
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
R3,150 per person and R6,300 per family
From day-to-day benefit
Over-the-counter:
R1,100 OR access to full savings for OTC purchases after R1,100 self payment.
Includes sunscreen, vitamins, minerals
Birth Control:
R2,678 per person
IUD insertion: once every 5 years
On Discharge:
7 days
Biological:
R192,126 per person
Treatment that is required (by law) for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here.)
Note:
Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
A quick guide to how you can change your medical aid plan, including the resignation procedure, and things to look out for, such as imposed waiting periods from your new scheme
