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:
|
| 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:
|
| 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:
|
| 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 |
|
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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 info@babyhealth.co.za or you can call us on 086 111 1936.
Please note that you may only register after the 12th week of pregnancy
