Bestmed Pace 4 medical aid plan: 2019

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Pace 4
2019 Costs:
Total Cost pm:

Main member:

R7,330

Adult:

R7,330

Child: (Pay only for first 4)

R1,665
Savings: R2640 R2640 R624
Extended Fund: RM= R32,465
M1+= R52,353
R R
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In brief (2018):
  • Scheme rate is 100%, (gap increases this to 500%)
  • Most day-to-day expenses are paid by scheme, or from savings or from out of pocket, unless PMBs
  • Bestmed supplements your savings for some out of hospital claims with an extra fund
  • Bestmed pays for maternity consults and scans
  • Cancer cover includes biological medicine (limit increased with gap cover)
  • Bestmed pays for refractive surgery
  • Treatment and medicine for 52 chronic conditions covered by scheme
  • There is a benefit for out-of-hospital specialised radiology (gap increases the limit)
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
See full benefits below

IN HOSPITAL PROCEDURES:
Pace 4
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:
  • 100% scheme rate
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 4
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: R2640 R2640 R624
Extended Fund: RM= R32,465
M1+= R52,353
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, up to R5,106 per person and R8,278 per family
  • Shared with specialist benefit
Childcare:
  • No extra benefits
Specialists consultations:
  • Shared with GP benefits, see above
Pathology:
  • R5,106 per person and R10,051 per family
  • From savings first, then from extra fund
  • Shared with radiology benefit
General radiology:
  • Shared with pathology benefits, see above
Specialised radiology:
  • Bestmed pays for 3 MRI/CT scans and 1 PET scan per person
  • All else is paid by you out-of-pocket
Supplementary Services: (Physio, etc)
  • R5,106 per person and R10,051 per family
  • From day-to-day benefit
What next?
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MATERNITY BENEFITS:
Pace 4
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 4
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • Oncology programme
  • Biological medicine: R445,480 per person
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

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DENTISTRY:
Pace 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, up to R11,275 per person and R19,030 per family
  • Benefit shared with specialised dentistry
Specialised Dentistry:
  • Specialised dentistry: from day-to-day benefit, up to R11,275 per person and R19,030 per family
  • Benefit shared with standard dentistry
In-Hospital Dentistry:
  • Preventative dentistry: paid by Bestmed. Includes exam, radiographs, scaling and polishing, fissure sealing and space maintainers
  • Standard and specilaized dentistry: From day-to-day benefit (savings first), up to M= R11,275 and M1+ = R19,030
  • Dental and oral surgery: R18,275 per family
  • PMB conditions (eg. fracture of face bones, orbit or/and jaw) are always paid by schemes. More info on PMBs
Orthodontics:
  • Subject to pre-authorisation and overall dentistry limits as above
Maxillo Facial Surgery:
  • Up to 100% scheme rate
  • Other dental/oral surgery: R17,000 per family
  • PMB conditions (eg. fracture of face bones, orbit or/and jaw) are always paid by schemes. More info on PMBs
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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MEDICATION:
Pace 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 26 non-CDL conditions are covered at 85% scheme rate, with an overall limit of R18,006 per person and R36,174 per family
  • If you voluntarily use medicine that is not on Bestmed's list ("formulary"), you pay a 20% co-payment
Acute (presrcibed) medication:
  • Limited to R8,063 per person and R12,524 per family
  • 10% co-payment
  • From day-to-day benefit
Over-the-counter:
  • From savings
Birth Control:
  • R2,097 per family per year, paid by Bestmed
On Discharge:
  • 7 days
Biological:
  • R445,480 per person
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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OPTOMETRY:
Pace 4
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:R9,138 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.

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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MENTAL HEALTH:
Pace 4
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
  • Otherwise, limited to R4,750 per person and R7,700 per family, paid from day-to-day benfit and shared with GP and Specialist benefits
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Trauma:
  • Up to 100% scheme rate
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 4
Scheme Benefits Notes and Links:
General Appliances:
  • Out of hospital, paid from savings first, then extra fund, up to R9,460 per family
  • In-hospital, 100% scheme rate
  • No benefit
1.1. Hearing Aids:
  • R32,680 per family, every 2 years
1.2. Wheelchairs:
  • R12,793 per family every 4 years
Dialysis:
  • Up to 100% scheme rate
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: R12,470 per family
  • From day-to-day benefit, unless PMB
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 4
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:
  • Covered
HIV Test:
Other:
  • HPV and HIB Vaccinations
  • Bone densitometry
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 4
Scheme Benefits: Notes and Links:
Overal Limit:
  • Internal: R121,690 per family
  • External: R28,058 per family
Sub-limits:
    (per person):
  • Functional (treating or supporting a bodily function): R16,600
  • Vascular: R45,150
  • Pacemaker, dual chamber: R56,706
  • Spinal, including artificial disk: R60,850
  • Drug-eluting stent: R20,264
  • Mesh: R17,845
  • Gynaecology/Urology: R14,728
  • Lens implants: R16,308 per lens
  • Hip replacement/prosthesis and other major joints: R54,449
  • Knee prosthesis: R63,049
  • Minor joints: R20,264
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