Bestmed Pace 4 medical aid plan: 2020

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Pace 4
2020 Costs:
Total Cost pm:

Main member:

R7,983

Adult:

R7,983

Child:

R1,870
Savings: R2880 R2880 R684
Extended Fund: RM= R34,153
M1+= R55,075
R R



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IN HOSPITAL PROCEDURES:
Pace 4
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • The Blue Plan gap cover will increase this to 500% scheme rate
network Specialists:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
non-Network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Hospital Choice:
  • Choose any hospital
Penalty for using other hospital:
  • 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:
  • 100% scheme rate
Co-payments:
  • None
Alternatives to hospitals:
  • Bestmed pays up to 100% scheme rate
Casualty:
  • No benefit, unless PMB
  • Both the Blue Plan and Red Plan gap cover will pay up to R20,000 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 R157,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R157,000 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 Notes and Links:
Main Member: Adult: Child:
Extended Fund: RM= R34,153
M1+= R55,075
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:
  • Subject to day-to-day benefit, savings first)
  • M =R5,372 and M+ =R8,708
  • 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:
  • Subject to day-to-day benefit, savings first)
  • M =R5,372 and M+ =R10,574
  • Shared with standard radiology benefit
  • See Primary Health Care benefit above
General radiology:
  • Shared with pathology benefits, see above
  • See Primary Health Care benefit above
Specialised radiology:
  • MRI/CT scans: Scheme pays for 3 scans per person
  • PET scans: Scheme pays for 1 scan per person
Supplementary Services: (Physio, etc)
  • M =R5,372 and M+ =R10,574
  • From day-to-day benefit, (savings first)



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MATERNITY BENEFITS:
Pace 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 Bestmed:
  • 9 consults, at GP/gynae/midwife
  • Iron and folic acid supplements
  • Post natal consult with GP/gynae/midwife
Scans:
    Bestmed pays for:
  • 2 x 2D scans



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CANCER (ONCOLOGY):
Pace 4
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • Oncology programme
  • Biological medicine: R468,645 per person
  • Mammmary surgery (breast cancer): R35,000



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DENTISTRY:
Pace 4
Scheme Benefits Notes and Links:
Standard Dentistry:
  • From day-to-day benefit
  • M =R11,861 and M+ =R20,020
  • 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
  • M =R11,861 and M+ =R20,020
  • Benefit shared with standard dentistry
In-Hospital Dentistry:
  • Dental and oral surgery: R19,225 per family
Orthodontics:
  • Subject to pre-authorisation and overall dentistry limits as above
Maxillo Facial Surgery:
  • Up to 100% scheme rate
  • 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:
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 28 non-CDL conditions are covered at 90% scheme rate, with an overall limit of M= R18,942 and M+ =R38,055
  • If you voluntarily use medicine that is not on Bestmed's list ("formulary"), you pay a 15% - 20% co-payment
Acute (presrcibed) medication:
  • M =R8,482 and M+ =R13,175
  • From 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:
  • From savings
Birth Control:
  • R2,205 per family per year, paid by Bestmed
On Discharge:
  • 7 days
Biological:
  • R468,645 per person



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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:R868
Single lenses100% cost from network, or R184
Bifocals:100% cost from network, or R431
Multifocals100% cost from network, or R747
ContactsR1,510
Refractive Surgery:R9,613 per eye



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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 R30,760 per person
Out-of-hospital:
  • PMBs always paid in full at DSP, and include consultations
  • Otherwise, M =R5,372 and M+ =R8,708
  • Shared with GP and specialist benefit
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:
Pace 4
Scheme Benefits Notes and Links:
General Appliances:
  • Out of hospital, R9,952 per family from day-to-day benefit (savings first)
  • In-hospital, 100% scheme rate
1.1. Hearing Aids:
  • R34,379 per person, every 2 years
1.2. Wheelchairs:
  • R13,458 per family every 4 years
Dialysis:
  • Up to 100% scheme rate
International Insurance:
    In brief (all subject to conditions of policy):
  • Medical expenses up to R10 million and maximum 90 days
Other:
  • Wound care: R13,118 per family, from day-to-day benefit, savings first
  • Insulin Pump: R40,000 per person



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WELLNESS/PREVENTATIVE BENEFITS:
Pace 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
  • Bone densitometry
  • Tempo Programme which includes bio screening, child assessments, nutrition assessments, fitness and nutritional interventions (biokineticist and dietician consults)



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PROSTHETICS:
Pace 4
Scheme Benefits: Notes and Links:
Overal Limit:
  • Overall: R128,018 per family
  • External: R29,517 per family
Sub-limits:
    (per person):
  • Functional (treating or supporting a bodily function): R18,773
  • Vascular: R47,498
  • Pacemaker, dual chamber: R59,655
  • Spinal, including artificial disk: R64,014
  • Drug-eluting stent: R21,318
  • Mesh: R18,773
  • Gynaecology/Urology: R15,494
  • Lens implants: R17,156 per lens
  • Hip replacement/prosthesis and other major joints: R57,280
  • Knee prosthesis: R66,328
  • Minor joints: R21,318



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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