Bestmed Pace 4 medical aid plan: 2019

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Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

Pace 4
2018 Costs:
Total Cost pm:

Main member:

R6,608

Adult:

R6,608

Child: (Pay only for first 4)

R1,548
Savings Account (yr): R2376 R2376 R552
Extended Fund: RM= R30,200
M1+= R48,700		 R R
2019 Costs:
Total Cost pm:

Main member:

R7,330
(10.93%)

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: Gap Benefits:
Specialists:
  • Up to 100% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
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Hospital Choice:
  • Choose any hospital
  • No extra benefit necessary
Specialised Radiology:
  • 100% scheme rate
  • No extra benefit necessary
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
Transplants:
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
Co-payments:
  • None
  • No extra benefit necessary
Alternatives to hospitals:
  • Bestmed pays up to 100% scheme rate
  • You pay the balance, if any
  • No extra benefit available
Casualty:
  • No benefit, unless PMB
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • N/A
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)
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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 Gap benefits
Main: Adult: Child:
Savings /yr: R2376 R2376 R552
Extended Fund: RM= R30,200
M1+= R48,700		 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.
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • From day-to-day benefit, unless PMB, up to R5,106 per person and R8,278 per family
  • Shared with specialist benefit
  • No extra benefit available
Childcare:
  • No extra benefits
  • No extra benefit available
Specialists consultations:
  • Shared with GP benefits, see above
  • No extra benefit available
Pathology:
  • R5,106 per person and R10,051 per family
  • From savings first, then from extra fund
  • Shared with radiology benefit
  • No extra benefit available
General radiology:
  • Shared with pathology benefits, see above
  • No extra benefit available
Specialised radiology:
  • Bestmed pays for 3 MRI/CT scans and 1 PET scan per person
  • All else is paid by you out-of-pocket
  • No extra benefit available
Supplementary Services: (Physio, etc)
  • R5,106 per person and R10,051 per family
  • From day-to-day benefit
  • No extra benefit available
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MATERNITY BENEFITS:
Pace 4
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
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
  • No extra benefit available
Scans:
    Bestmed pays for:
  • 4 scans
  • No extra benefit available
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CANCER (ONCOLOGY):
Pace 4
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Oncology programme
  • Biological medicine: R445,480 per person
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, the gap cancer benefit will cover costs authorised but not paid by your medical scheme (up to the R150,000 per person per year gap cover limit). This includes extra cover for biological medicine short-payments or co-payments. More info
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DENTISTRY:
Pace 4
Scheme Benefits Gap benefits
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
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)
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
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)
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MEDICATION:
Pace 4
Scheme Benefits Gap benefits
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
  • No extra benefit available
Acute (presrcibed) medication:
  • Limited to R8,063 per person and R12,524 per family
  • 10% co-payment
  • From day-to-day benefit
  • No extra benefit available
Over-the-counter:
  • From savings
  • No extra benefit available
Birth Control:
  • R2,097 per family per year, paid by Bestmed
  • No extra benefit available
On Discharge:
  • 7 days
  • No extra benefit available
Biological:
  • R445,480 per person
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, the gap cancer benefit will cover costs authorised but not paid by your medical scheme (up to the R150,000 /person /year gap cover limit). This includes extra cover for biological medicine short-payments or co-payments. More info
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OPTOMETRY:
Pace 4
Scheme Benefits Gap benefits
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
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)
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MENTAL HEALTH:
Pace 4
Scheme Benefits Gap benefits
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
  • No extra benefit available
  • (PMBs are paid in full by scheme if you use DSP)
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
  • No extra benefit available
  • (PMBs are paid in full by scheme if you use DSP)
Trauma:
  • Up to 100% scheme rate
  • No extra benefit available
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OTHER BENEFITS:
Pace 4
Scheme Benefits Gap benefits
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
  • No benefit
1.2. Wheelchairs:
  • R12,793 per family every 4 years
  • No benefit
Dialysis:
  • Up to 100% scheme rate
  • Gap cover will pay shortfall for authorised in and out-of-hospital treatment
  • Note that gap does not pay penalties, for example if you have a co-payment because you voluntarily opted to use a non-DSP
HIV:
  • Managed care programme, which includes pathology tests, doctor consults, medicine and hospital treatment]
  • No benefit
Emergency Transport:
  • ER24
  • No benefit
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
  • No benefit
Other:
  • Wound care: R12,470 per family
  • From day-to-day benefit, unless PMB
  • No extra benefit available
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WELLNESS/PREVENTATIVE BENEFITS:
Pace 4
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • Twice in a lifetime, with a booster above 65yrs
  • No benefit
Back Rehabilitation Programme:
  • 6 weeks, once a year
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered, 18yrs+ every 2 years
  • No benefit
Mammogram:
  • Once every 24 months
  • No benefit
PAS Test:
  • Covered
  • No benefit
HIV Test:
  • No benefit
Other:
  • HPV and HIB Vaccinations
  • Bone densitometry
  • No benefit
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PROSTHETICS:
Pace 4
Scheme Benefits Gap benefits
Overal Limit:
  • Internal: R121,690 per family
  • External: R28,058 per family
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
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
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
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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