Bestmed Beat 4 medical aid plan: 2020

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Beat 4
Total Cost pm:

Main member:

R4,685

Adult:

R3,869

Child:

R1,158
Savings: R7,872 R6,492 R1,944
Extended Fund: R R R

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IN HOSPITAL PROCEDURES:
Beat 4
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • 100% scheme rate
network Specialists:
  • 100% scheme rate
non-Network GPs:
  • 100% scheme rate
network GPs:
  • 100% scheme rate
Hospital Choice:
  • Choose from any hospitals
Penalty for using other hospital:
  • n/a
  • n/a
Specialised Radiology:
  • 100% scheme rate
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • PMBs only
Co-payments:
  • None
Alternatives to hospitals:
  • Scheme pays up to 100% scheme rate
Casualty:
  • No benefit, unless PMB
  • Both the Blue Plan and Red Plan gap cover will pay up to R10,000 per person for unpaid casualty costs in event of emergency
Other:
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R165,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R165,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Beat 4
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Extended Fund: R R R
General info:
  • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
GP consultations:
  • From day-to-day benefit, unless PMB (savings first), up to R3,110 per person and R5,541 per family
  • Shared with specialist benefit
  • See Primary Health Care benefit above
Childcare:
  • No extra benefits
Specialists consultations:
  • Shared with GP benefits, see above
  • See Primary Health Care benefit above
Pathology:
  • R3,110 per person and R6,333 per family
  • From day-to-day benefit, (savings first)
  • Shared with general radiology benefit
  • See Primary Health Care benefit above
General radiology:
  • Shared with pathology benefits, see above
  • See Primary Health Care benefit above
Specialised radiology:
  • Bestmed pays up to R16,172 per family
  • You or your gap cover pay the balance
Supplementary Services: (Physio, etc)
  • R4,750 per person and R9,647 per family
  • From day-to-day benefit, (savings first)

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MATERNITY BENEFITS:
Beat 4
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
    Paid by scheme:
  • 9 consults with GP, gynaecologist or midwife
  • 1 x post-natal consult with GP, gynaecologist or midwife
  • Antenatal iron supplements
  • Antenatal folic acid
Scans:
    Paid by scheme:
  • 2 x 2D ultrasound scans

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CANCER (ONCOLOGY):
Beat 4
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • PMBs only, at DSP (designated service provider)

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DENTISTRY:
Beat 4
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Preventative dentistry: paid by Bestmed. Includes exam, radiographs, scaling and polishing, fissure sealing and space maintainers
  • Standard dentistry: from day-to-day benefit (savings first), up to R5,381 per person and R10,808 per family
  • Benefit shared with specialised dentistry
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Specialised Dentistry:
  • From day-to-day benefit, up to R5,381 per person and R10,808 per family
  • Benefit shared with standard dentistry
In-Hospital Dentistry:
  • Dental and oral surgery: R9,613 per family
Orthodontics:
  • Subject to pre-authorisation
Maxillo Facial Surgery:
  • R12,554 per family paid by scheme
  • PMB conditions (eg. fracture of face bones, orbit or/and jaw) are always paid by schemes. More info on PMBs

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MEDICATION:
Beat 4
Scheme Benefits: Notes and Links:
Chronic:
  • All medical aid plans pay for treatment of the 27 CDL conditions as required by law. This includes medicine as well as GP or specialist consults, tests etc. Find out more
  • An additional 9 non-CDL conditions are covered at 90% scheme rate, with an overall limit of M =R7,204 and M1+ =R14,408 per family
  • If you voluntarily use medicine that is not on Bestmed's list ("formulary"), you pay a 25% co-payment
Acute (presrcibed) medication:
  • M =R2,748 and M1+ =R5,552 per family
  • Subject to day-to-day benefit, (savings first)
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Over-the-counter:
  • R650
Birth Control:
  • R2,205 per family per year, paid by Bestmed
On Discharge:
  • 7 days
Biological:
  • No benefit, unless PMB level of care

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OPTOMETRY:
Beat 4
Scheme Benefits: Notes and Links:
Optometry:
Limit:Paid by scheme, every 24 months
Consult:1 per person
Frames:R868
Single lenses100% cost
Bifocals:100% cost
Multifocals100% cost
ContactsR1,510 as alternative to glasses
Refractive Surgery:R8,935 per eye
Notes:Above benefits from network provider. Other limits apply to non-network providers.

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MENTAL HEALTH:
Beat 4
Scheme Benefits Notes and Links:
In-hospital:
  • 21 days per person
  • Subject to PMBs and Designated Service Providers
  • Alcoholism/Drug Addiction: 21 days per person or R30,760 per person. Network facilities.
Out-of-hospital:
  • PMBs always paid in full at DSP, and include consultations
Trauma:
  • PMB conditions are covered for in and out of hospital treatment. For a full list see here.
  • Example of PMB condition: Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts

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OTHER BENEFITS:
Beat 4
Scheme Benefits Notes and Links:
General Appliances:
  • Out of hospital, R10,970 per family subject to day-to-day benefit (savings first)
  • In-hospital: 100% scheme rate
1.1. Hearing Aids:
  • See above
1.2. Wheelchairs:
  • See above
Dialysis:
  • 100% scheme rate, with a designated network provider
International Insurance:
    In brief (all subject to conditions of policy):
  • Medical expenses up to R10 million and maximum 90 days
Other:
  • Wound care: R4,750 per family, subject to day-to-day benefit, (savings first)

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WELLNESS/PREVENTATIVE BENEFITS:
Beat 4
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, 18yrs+ every 2 years
Mammogram:
  • Covered, women 40yrs+, every two years
PAS Test:
  • Covered, 50yrs+ every 2 years
HIV Test:
Other:
  • HPV and HIB Vaccinations
  • Tempo Programme which includes bio screening, child assessments, nutrition assessments, fitness and nutritional interventions (biokineticist and dietician consults)

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PROSTHETICS:
Beat 4
Scheme Benefits: Notes and Links:
Overal Limit:
  • Internal: R92,629 per family
  • External: R22,279 per family
Sub-limits:
    (per person):
  • Functional (treating or supporting a bodily function): R16,172
  • Vascular: R32,005
  • Pacemaker, dual chamber: R53,605
  • Spinal: R32,005
  • Mesh: R11,875
  • Gynaecology/Urology: R8,708
  • Drug eluting stents:R17,982
  • Lens implants: R6,785 per lens
    Exclusions:
  • Endovascular and catheter-based procedures
  • Artificial disk
  • Joint replacements, unless PMB
    PMB joint replacements - prothesis limits:
  • Hip replacement and other major joints: R32,910
  • Knee replacement: R43,721
  • Minor Joints: R13,434

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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised