Bestmed Pace 1 medical aid plan: 2019

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Pace 1
2019 Costs:
Total Cost pm:

Main member:

R3,609

Adult:

R2,534

Child: (Pay only for first 4)

R911
Savings: R8,232 R5,772 R2,076
Extended Fund: RM= R9,868
M1+= R19,737
R R
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IN HOSPITAL PROCEDURES:
Pace 1
Scheme Benefits: Notes and Links:
Specialists:
  • Up to 100% scheme rate
  • You or gap cover pay the balance, if any
Gap Cover
  • Gap cover is available for this plan. Budget about R350 for a fully comprehensive gap cover that will increase the scheme rate to 500% and pay most co-payments and increase sublimits.
Hospital Choice:
  • Choose any hospital
Specialised Radiology:
  • 100% scheme rate
Supplementary Services: (Physio, etc)
  • 100% scheme rate
Transplants:
Co-payments:
  • None
Alternatives to hospitals:
  • Bestmed pays up to 100% scheme rate
  • You pay the balance, if any
Casualty:
  • No benefit, unless PMB
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 R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 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)
What next?
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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):
Pace 1
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: R8,232 R5,772 R2,076
Extended Fund: RM= R9,868
M1+= R19,737
R R
General info:
  • This plan has a savings fund as well as an "extra" fund, so most out of hospital costs can be paid by this
  • Remember, out of hospital costs authorised as part of PMB treatment (eg. cancer, asthma or stroke) are always paid by the scheme, not out of savings.
GP consultations:
  • From day-to-day benefit, unless PMB (savings first), up to R2,032 per person and R4,085 per family
  • Shared with specialist benefit
Childcare:
  • No extra benefits
Specialists consultations:
  • Shared with GP benefits, see above
Pathology:
  • R2,956 per person and R5,913 per family
  • From day-to-day benefit, (savings first)
  • Shared with general radiology benefit
General radiology:
  • Shared with pathology benefits, see above
Specialised radiology:
  • Bestmed pays up to R13,223 per family
  • You or your gap cover pay the balance
Supplementary Services: (Physio, etc)
  • R3,988 per person and R8,278 per family
  • From day-to-day benefit, (savings first)
What next?
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MATERNITY BENEFITS:
Pace 1
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate
Consultations:
    Paid by Bestmed:
  • 9 consults, at GP/gynae/midwife
  • 4 x 2D specific scans
  • Iron and folic acid supplements
  • Post natal consult with GP/gynae/midwife
Scans:
    Bestmed pays for:
  • 4 scans
What next?
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CANCER (ONCOLOGY):
Pace 1
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • Oncology programme, with PMB cancers at DSPs (Designated Service Providers) only
What next?
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DENTISTRY:
Pace 1
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 R3,740 per person and R7,590 per family
  • Benefit shared with specialised dentistry
Specialised Dentistry:
  • Specialised dentistry: from day-to-day benefit, up to R3,740 per person and R7,590 per family
  • Benefit shared with standard dentistry
In-Hospital Dentistry:
  • Dental and oral surgery: R7,310 per family
Orthodontics:
  • Subject to pre-authorisation and overall dentistry limits as above
Maxillo Facial Surgery:
  • R11,825per family paid by Bestmed
  • Other dental/oral surgery: R6,800 per family
  • PMB conditions (eg. fracture of face bones, orbit or/and jaw) are always paid by schemes. More info on PMBs
What next?
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Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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MEDICATION:
Pace 1
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 7 non-CDL conditions are covered at 85% scheme rate, with an overall limit of R6,020 per person and R12,040 per family
  • If you voluntarily use medicine that is not on Bestmed's list ("formulary"), you pay a 35% co-payment
Acute (presrcibed) medication:
  • Limited to R2,129 per person and R4,408 per family
  • From day-to-day benefit, (savings first)
Over-the-counter:
  • From savings, limited to R550
Birth Control:
  • R2,097 per family per year, paid by Bestmed
On Discharge:
  • 7 days
Biological:
  • No benefit, unless PMB level of care
What next?
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OPTOMETRY:
Pace 1
Scheme Benefits: Notes and Links:
Optometry:
Limit:Paid by scheme, every 24 months
Consult:1 per person
Frames:R825
Single lenses100% cost
Bifocals:R410
MultifocalsR710
ContactsR1,435
Refractive Surgery:R8,127 per eye
Notes:Above benefits from network provider
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

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MENTAL HEALTH:
Pace 1
Scheme Benefits Notes and Links:
In-hospital:
  • In-hospital: PMBs always paid in full at DSP, and include up to 21 days admission
  • Treatment of chemical or substance abuse: PMB level of care or R29,240 per person
Out-of-hospital:
  • Out-of-hospital: PMBs always paid in full at DSP, and include consultations
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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
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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OTHER BENEFITS:
Pace 1
Scheme Benefits Notes and Links:
General Appliances:
  • Out of hospital, R10,428 per family from day-to-day benefit (savings first)
  • In-hospital, 100% scheme rate
  • No benefit
1.1. Hearing Aids:
  • See "General Appliances" limit. Paid every 24 months.
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • Bestmed only pays for PMB cases, with a designated network provider
HIV:
  • Managed care programme, which includes pathology tests, doctor consults, medicine and hospital treatment]
Emergency Transport:
  • ER24
International Insurance:
    In brief (all subject to conditions of policy):
  • Available to all members between the age of 3 months and 84 years old
  • Medical expenses up to R10 million. Pre-existing conditions or sequelae thereof limited to R250,000
  • Cost of a visit by a family member when severe illness or injury has occurred
  • Return to South Africa, if deemed necessary
Other:
  • Wound care: R3,279 per family
  • First from savings, then extra fund if available
  • Rehab after trauma: vested savings
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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WELLNESS/PREVENTATIVE BENEFITS:
Pace 1
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Twice in a lifetime, with a booster above 65yrs
Back Rehabilitation Programme:
  • 6 weeks, once a year
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, 18yrs+ every 2 years
Mammogram:
  • Once every 24 months
PAS Test:
HIV Test:
Other:
  • HPV and HIB Vaccinations
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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PROSTHETICS:
Pace 1
Scheme Benefits: Notes and Links:
Overal Limit:
  • Internal: R81,700 per family
  • External: R20,748 per family
Sub-limits:
    (per person):
  • Functional (treating or supporting a bodily function): R13,650
  • Vascular: R29,777
  • Pacemaker, dual chamber: R50,848
  • Spinal: R29,777
  • Mesh: R11,180
  • Gynaecology/Urology: R9,063
  • Lens implants: R6,128 per lens
  • Drug eluting stents: DSP products only
    Exclusions:
  • Endovascular and catheter-based procedures
  • Artificial disk
  • Joint replacements, unless PMB
    PMB joint replacements - prothesis limits:
  • Hip replacement and other major joints: R30,315
  • Knee replacement: R40,313
  • Minor Joints: R12,524
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.


    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