Bestmed Beat 4 Option

The Bestmed Beat 4 option is superior hybrid option for young to middle-aged families that required specific health care packages. This option provides comprehensive in-hospital benefits at private hospitals. You will also get a generous amount of day-to-day medical cover for consultations, dentistry, chronic medications and a range of preventative care benefits.

Who should not choose this option?

The Bestmed Beat options is not suited for older individuals and families as they require more day-to-day expenses cover and certain diseases. If you need more cover from a medical aid, please refer to Bestmed’s Pace Options.

Bestmed Beat 4 Option Benefits

  • Savings Account: Available
  • Day-to-day Benefits: Available
  • Over the Counter: Available

Value Benefits

  • No automatic self-payment gaps
  • Preventative care benefits
  • FP and Specialist consultations
  • Optometry
  • Maternity benefits
Contributions
Principal Member Adult Dependant Child Dependant*
Risk Amount R3 334 R2 753 R824
Savings Amount R588 R486 R146
Total Monthly Contribution R3 922 R3 239 R970

* You only pay for a maximum of 4 children. All other children can join as beneficiaries of the Scheme free of charge.

Method of Benefit Payment

On the Bestmed Beat 4 option in-hospital services are paid from the Scheme risk. Some out-of-hospital services are paid from the annual savings first and, once depleted, will be paid from the day-to-day benefit. Once the day-to-day benefit is depleted, services can be paid from the available vested savings. Some preventative care is available from the Scheme risk benefit.

In-hospital Benefits
  • All in-hospital benefits referred to in the section below require pre-authorisation
  • Clinical protocols,preferred providers, designated service providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP) may apply
Medical Event Scheme Benefit
Accommodation (hospital stay) and theatre fees 100% Scheme tariff
Take-home medicine 100% Scheme tariff – Limited to 7 days’ medicine
Treatment in mental health clinics 100% Scheme tariff – Limited to 21 days per beneficiary
Treatment of chemical and substance abuse 100% Scheme tariff – Limited to 21 days or R27 200 per beneficiary & subject to network facilities
Consultations and procedures 100% Scheme tariff
Surgical procedures and anaesthetics 100% Scheme tariff
Organ transplants 100% Scheme tariff (Only PMBs)
Major medical maxillo-facial surgery strictly related to certain conditions 100% Scheme tariff – limited to R11 100 per family
Dental and oral surgery Limited to R8 500 per family
Prosthesis
(Subject to preferred provider, otherwise limits and co-payments apply)
100% Scheme tariff. Limited to R81 900 per family
Prosthesis – Internal
Note: Sub-limit subject to the prosthesis limit
Sub-limits per beneficiary:

  • *Functional limited to R14 300
  • Pacemaker (dual chamber) R47 400
  • Vascular R28 300
  • Endovascular and catheter-based procedures – no benefit
  • Spinal R28 300
  • Artificial disk – no benefit
  • Drug-eluting stents R15 900
  • Mesh R10 500
  • Gynaecology/Urology R7 700
  • Lens implants R6 000 per lense
Prosthesis – External Limited to R19 700 per family
Exclusions
Limits and co-payments applicable
Preferred provider network available.
Joint replacement surgery (except for PMBs). PMBs subject to prosthesis limits:

  • Hip replacement and other major joints R29 100
  • Knee replacement R38 660
  • Minor joints R11 880
Orthopaedic and medical appliances 100% Scheme tariff
Pathology 100% Scheme tariff
Diagnostic imaging 100% Scheme tariff
Specialised diagnostic imaging 100% Scheme tariff
Oncology Oncology programme
100% Scheme tariff
Peritoneal dialysis and haemodialysis 100% Scheme tariff – subject to pre-authorisation
Confinements 100% Scheme tariff
Refractive surgery 100% Scheme tariff
subject to pre-authorisation and protocols
limited to R7 900 per eye
Midwife-assisted births 100% Scheme tariff
Supplementary services 100% Scheme tariff
Alternatives to hospitalisation 100% Scheme tariff
Emergency Evacuation 100% Scheme tariff.
Pre-authorised and rendered by ER24
Out-of-hospital Benefits
  • Benefits below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP)
  • Some indicated benefits are paid from the annual savings account first at 100% of the Scheme tariff
  • Once the annual savings account is depleted, benefits will be paid from Scheme’s day-to-day benefits (limits apply)
  • All unused funds in the annual savings account at the end of the year will be carried over to the vested medical savings account of the following financial year and will remain your property and also accumulate to your credit
  • Funds in the vested medical savings account will only be utilised when both the annual savings account and the Scheme risk benefits are depleted

The following out-of-hospital benefits are paid for by the Scheme:

Medical Event Scheme Benefit
Overall day-to-day limit M = R10 800, M1+ = R21 600
FP and Specialist Consultations Savings first
Limited to M = R2 750, M1+ = R4 900
(subject to overall day-to-day limit)
Basic & Specialised Dentistry Savings first
Orthodontics are subject to pre-authorisation
Limited to M = R4 650, M1+ = R9 340
(subject to overall day-to-day limit)
Medical Aids, Apparatus & Appliances Savings first
100% Scheme tariff
Limited to R9 700 per family
(subject to overall day-to-day limit)
Supplementary Services Savings first
Limited to M = R4 200, M1+ = R8 530
(subject to overall day-to-day limit)
Wound care benefit
(incl. dressings, negative pressure wound therapy treatment and related nursing services – out-of-hospital)
Savings first
100% Scheme tariff
Limited to R4 200 per family
(subject to overall day-to-day limit)
Optometry Benefit
(PPN capitation provider)
Optometry services are obtained from and paid by PPN at 100% of cost per beneficiary every 24 months.*
For services rendered by a non-network provider, the following maximum amounts per beneficiary apply every 24 months:

  • Consultation: R365
  • Frame: R550 AND
    • Single-vision lenses: R175 OR
    • Bifocal lenses: R380 OR
    • Multifocal lenses: R695
  • Contact lenses: R1 420**
Diagnostic Imaging & Pathology Savings first
Limited to M = R2 750, M1+ = R5 600
(subject to overall day-to-day limit)
Specialised diagnostic imaging 100% Scheme tariff – limited to R14 300 per family
Oncology Oncology programme
100% Scheme tariff
Peritoneal dialysis and haemodialysis 100% Scheme tariff – subject to pre-authorisation
Maternity Benefits 100% Scheme tariff – 2 sonars and up to 12 antenatal consultations
Rehabilitation services after trauma Vested savings

* This means the benefit is limited to only those products and services negotiated by PPN and only those frames specified by PPN.

** Preferred Provider Negotiators (PPN) will pay a maximum amount of R1 420 towards the cost for contact lenses per beneficiary every 24 months, irrespective of whether the beneficiary utilised the services of PPN or a non–network provider.

Medicine
  • Benefits below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP)
  • Approved CDL, PMB and non-CDL chronic medicine costs will be paid from the non-CDL limit first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk
Benefit Description Scheme Benefit
CDL & PMB chronic medicine* 100% Scheme tariff – co-payment of 30% for non-formulary medicine
Non-CDL chronic medicine* 9 Conditions – 85% Scheme tariff
Limited to M = R6 370, M1+ = R12 740.
Co-payment of 30% for non-formulary medicine
Biologicals and other high-cost medicine No benefit
Acute medicine Savings first
Limited to M = R2 430, M1+ = R4 910
(subject to overall day-to-day limit)
Over-the-counter (OTC) medicine * Member choice 1.: R550 OTC limit OR
2. Access to full PMSA for OTC purchases (after R550 limit) = self-payment gap accumulation

* The default OTC choice is 1. R550 OTC limit. Members wishing to choose the other option are welcome to contact Bestmed.

Preventative Care Benefits

Benefits below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP).

Preventative Care Benefit Gender & Age Group Quantity & Frequency Benefit Criteria
Flu Vaccines All ages 1 per beneficiary per year Applicable to all active members and beneficiaries
Pneumonia Vaccines Children < 2 years
High-risk adult group
Children: As per schedule of Department of Health
Adults: Twice in a lifetime with booster above 65 years of age
Adults: The Scheme will identify certain high-risk individuals who will be advised to be immunised
Paediatric Immunisations Babies and children Funding for all paediatric vaccines according to the state-recommended programme
Female Contraceptives All females of child-bearing age Quantity and frequency depending on product up to the maximum allows amount.
Mirena device – 1 device every 60 months
Limited to R1 950 per family per year.
Includes all items classified in the category of female contraceptives
Spinal/Back Treatment Programme (DBC) All ages 6 weeks, once per year Applicable to beneficiaries who have serious spinal and/or back problems and may require surgery. The Scheme may identify appropriate participants for evaluation at a DBC clinic. Based on the evaluation done by a DBC clinic, a rehabilitation treatment plan is drawn up and initiated which lasts 6 weeks, consecutively
Preventative Dentistry
(incl gloves & sterilie equipment)
Refer to Preventative Dentistry section for details
Haemophilus influenzae Type B vaccine (HIB)  Children 5 years or younger 1 vaccine at 6, 10 and 14 weeks after birth
1 booster vaccine between 15 – 18 months
If the booster vaccine was not administered timeously, the maximum age to which it will be allowed is 5 years
Mammogram Females 40 years and older Once every 24 months Scheme tariff is applicable
HPV Vaccinations Females of 9 – 26 years old 3 vaccinations per beneficiary Vaccinations will be funded at MRP
PSA Screening Males 50 years and older Once every 24 months
Pap Smear Females 18 years and older Once every 24 months Can be done at a gynaecologist or FP. Consultation paid from the available savings/consultations benefit.
BetterMe Wellness Benefits
Note: BIometric screening activates the other assessment benefits
  • Health risk assessment (biometric screening) at contracted pharmacy or on-site at employer
  • Fitness assessment at a contracted BASA biokineticist – 1 per beneficiary per year (ages older than 13 years)
  • Nutritional assessment – 1 per family per year
  • Occupational therapy assessment – 1 per beneficiary per year (ages 3-12 years)
  • Baby growth assessment at a contracted pharmacy clinic – 3 per beneficiary per year (ages 0-35 months)
Preventative Dentistry

Services mentioned below may be subject to pre-authorisation, clinical protocols and funding guidelines.

Description of Service Age Frequency
General full-mouth examination by a general dentist
(incl. gloves and use of sterile equipment for the visit)
Above 12 years
Under 12 years
Once a year
Twice a year
Full-mouth intra-oral radiographs All ages Once every 36 months
Intra-oral radiographs All ages 2x photos per year
Scaling and/or polishing All ages Twice a year
Fluoride treatment All ages Twice a year
Fissure sealing Up to and including 21 years In accordance with accepted protocol
Space maintainers During primary and mixed denture stage Once per space
Chronic / Non-Chronic Conditions List (CDL / Non-CDL)
Chronic Disease List (CDL)
CDL 1 Addison’s disease
CDL 2 Asthma
CDL 3 Bipolar mood disorder
CDL 4 Bronchiectasis
CDL 5 Cardiomyopathy
CDL 6 Chronic renal disease
CDL 7 Chronic obstructive pulmonary disease (COPD)
CDL 8 Cardiac failure
CDL 9 Coronary artery disease
CDL 10 Crohn’s disease
CDL 11 Diabetes insipidus
CDL 12 Diabetes mellitus type 1
CDL 13 Diabetes mellitus type 2
CDL 14 Dysrhythmias
CDL 15 Epilepsy
CDL 16 Glaucoma
CDL 17 Haemophilia
CDL 18 Hyperlipidaemia
CDL 19 Hypertension
CDL 20 Hypothyroidism
CDL 21 Multiple sclerosis
CDL 22 Parkinson’s disease
CDL 23 Rheumatoid arthritis
CDL 24 Schizophrenia
CDL 25 Systemic lupus erythematosus (SLE)
CDL 26 Ulcerative colitis
Non-Chronic Disease List (Non-CDL)
Non-CDL 1 Acne – severe
Non-CDL 2 Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD)
Non-CDL 3 Allergic rhinitis
Non-CDL 4 Eczema – severe
Non-CDL 5 Migraine prophylaxis
Non-CDL 6 Gout prophylaxis
Non-CDL 7 Major depression
Non-CDL 8 Obsessive compulsive disorder
Non-CDL 9 Gastro oesophageal reflux disease (GORD)
Prescribed Minimum Benefits (PMB)
Prescribed Minimum Benefits (PMB)
PMB 1 Aplastic anaemia
PMB 2 Chronic anaemia
PMB 3 Benign prostatic hypertrophy
PMB 4 Cushing’s disease
PMB 5 Cystic fibrosis
PMB 6 Endometriosis
PMB 7 Female menopause
PMB 8 Fibrosing alveolitis
PMB 9 Graves’ disease
PMB 10 Hyperthyroidism
PMB 11 Hypophyseal adenoma
PMB 12 Idiopathic thrombocytopenic purpura
PMB 13 Paraplegia/Quadriplegia
PMB 14 Polycystic ovarian syndrome
PMB 15 Pulmonary embolism
PMB 16 Stroke
Maternity Care Programme

With so many things to juggle, the Maternity Care programme is here to help moms and dads through their entire pregnancy and the first two years with a new little one in the home. At Bestmed, we want you to enjoy this entire experience and feel comfortable knowing that we are here for you.

Registering on this programme will give you the following support and benefits:

  • A 24-hour professional medical advice line you can call with any queries, no matter how small.
  • Weekly e-mails packed with convenient information about your pregnancy, your baby’s development, how to deal with unpleasant pregnancy symptoms and useful hints.
  • Dads won’t be left out as they will also receive e-mails every second week to inform them about the baby’s development and Mom’s progress.
  • To make sure your pregnancy starts right, you will receive a welcome pack containing an informative pregnancy book to guide you through the stages as well as discount vouchers for various baby items.
  • In your second month after registration, we will send you a useful baby bag packed with products to use after your baby’s birth.

You are able to register on the Maternity Care programme simply by sending an e-mail to [email protected] or you can call us on 086 111 1936.

Please note that you may only register after the 12th week of pregnancy