Bestmed Pace 4 Option

The Bestmed Pace 4 option is Bestmed’s most comprehensive option. This option is ideal for a discerning family that want above average medical costs or want maximum medical cover. The Bestmed Pace 4 provides extensive benefits and cover for hospital expenses. In addition the savings account offers further payment flexibility. The Pace 4 provides the greatest cover with complete peace of mind.

Who should not choose this option?

Due to the Bestmed Pace 4’s comprehensive cover, this option might not be suited for young and healthy individuals or couples without families. Be sure to checkout Bestmed’s Beat 3, Pace 1, Beat 4 and Pace 2 options.

Bestmed Pace 4 Option Benefits

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

Value Benefits

  • No co-payment or automatic self-payment gaps
  • FP and Specialist consultations
  • Optometry
  • Dentistry
  • Maternity benefits
Contributions
Principal Member Adult Dependant Child Dependant*
Risk Amount R6 410 R6 410 R1 502
Savings Amount R198 R198 R46
Total Contribution R6 608 R6 608 R1 548

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

Method of Benefit Payment

On the Bestmed Pace 4 option in-hospital services, out-of-hospital services and preventative care are paid from Scheme risk. Once out-of-hospital risk benefits are depleted, further claims will be paid from savings.

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 (only PMBs)
Limited to 21 days per beneficiary 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
Major medical maxillo-facial surgery strictly related to certain conditions 100% Scheme tariff
Dental and oral surgery Limited to R17 000 per family
(This limit applies to both in- and out-of-hospital benefits)
Prosthesis
(Subject to preferred provider, otherwise limits and co-payments apply)
100% Scheme tariff.
Limited to R113 200 per family
Prosthesis – Internal
Note: Sub-limit subject to the prosthesis limit
Sub-limits per beneficiary:

  • *Functional limited to R16 600
  • Vascular: R42 000
  • Pacemaker (dual chamber): R52 750
  • Spinal: R42 000
  • Artificial disk: R18 850
  • Drug-eluting stents: R18 850
  • Mesh: R16 600
  • Gynaecology/Urology: R13 700
  • Lens implants: R15 170 per lens
  • Join replacements:
    • Hip replacement and other major joints: R50 650
    • Knee replacement: R58 650
    • Minor Joints: R18 950
Prosthesis – External Limit of R26 100 per family
Orthopaedic and medical appliances 100% Scheme tariff
Pathology 100% Scheme tariff
Diagnostic imaging 100% Scheme tariff
Specialised diagnostic imaging 100% Scheme tariff
Oncology 100% Scheme tariff
Oncology programme
Peritoneal dialysis and haemodialysis 100% Scheme tariff
Confinements 100% Scheme tariff
Refractive surgery 100% Scheme tariff
Limited to R8 500 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

Out-of-hospital benefits are paid at 100% Scheme tariff.

Subject to sub-limits and benefits available in the day-to-day overall limit.

Once the overall day-to-day limit is depleted, the member may request payment from the individual medical savings account (IMSA).

Should you not use all of the funds available in your medical savings account, these funds will be transferred into your savings account at the beginning of the following financial year.

Clinical funding protocols, preferred providers, designated service providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP) may apply.

Medical Event Scheme Benefit
Overall Day-to-day Limit M = R30 200, M1+ = R48 700
FP & Specialist Consultations Savings first
100% Scheme tariff
M = R4 750, M1+ = R7 700
(subject to overall day-to-day limit)
Basic & Specialised Dentistry Limited to M = R10 250, M1+ = R17 300
(subject to overall day-to-day limit)
Orthodontics are subject to pre-authorisation
Medical aids, apparatus and appliances including wheelchairs and hearing aids Limited to R8 800 per family.
(subject to overall day-to-day limit)
Limit on wheelchairs of R11 900 per family per 48 months
Limit on hearing aids of R30 400 per beneficiary per 24 months
Supplementary Services Limited to M = R4 750, M1+ = R9 350
(subject to day-to-day overall limit)
Wound Care Benefit
(incl. dressings, negative pressure wound therapy (NPWT) treatment and related nursing services – out-of-hospital)
Limited to R11 600 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 & Patholog Limited to M = R4 750, M1+ = R9 350
(subject to overall day-to-day limit)
Maternity Benefits 100% Scheme tariff
2 sonars and up to 12 antenatal consultations
Specialised Diagnostic Imaging MRI/CT scans: Maximum of 3 scans per beneficiary.
PET scan: 1 scan per beneficiary.
Rehabilitation Services After Trauma 100% Scheme tariff
Oncology 100% Scheme tariff
Oncology programme
Peritoneal Dialysis & Haemodialysis Subject to pre-authorisation and DSPs

* This means that 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
  • All benefits below may be subject to pre-authorisation, clinical protocols, formularies, funding guidelines and the Mediscor Reference Price (MRP)
  • Please note that 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 20% for non-formulary medicine
Non-CDL chronic medicine 26 conditions
85% Scheme tariff
Limited to M = R16 750, M1+ = R33 650
Co-payment of 20% for non-formulary medicine
Biologicals and other high-cost medicine Limited to R414 400 per beneficiary
Acute medicine Limited to M = R7 500, M1+ = R11 650
10% co-payment
(subject to overall day-to-day limit)
Over-the-counter (OTC) medicine Savings account
Preventative Care Benefits

100% Scheme tariff. Subject to Scheme protocols. Benefits below may be subject to the Mediscor Reference Price (MRP).

Preventative Care Benefit Gender & Age Group Quantity & Frequency Benefit Criteria
Flu Vaccines All ages 1 per beneficiary per year At a Bestmed Pulse 1 Network FP or network pharmacy only
Subject to Pulse 1 protocols and where clinically necessary
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 & 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 and sterile equipment)
Refer to Preventative Dentistry section for details
Haemophilus Influenzae Type B Vaccine (HIB) Children 5 years and 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
PSA Screening Males 50 years and older Once every 24 months
HPV Vaccinations Females of 9 – 26 years old 3 vaccinations per beneficiary Vaccinations will be funded at MRP
Bone Densitometry All beneficiaries 45 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/consultation 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 Osteoporosis
Non-CDL 10 Psoriasis
Non-CDL 11 Urinary incontinence
Non-CDL 12 Paget’s disease
Non-CDL 13 Gastro oesophageal reflux disease (GORD)
Non-CDL 14 Ankylosing spondylitis
Non-CDL 15 Hypopituitarism
Non-CDL 16 Osteoarthritis
Non-CDL 17 Alzheimer’s disease
Non-CDL 18 Collagen diseases
Non-CDL 19 Dermatomyositis
Non-CDL 20 Motor neuron disease
Non-CDL 21 Neuropathy
Non-CDL 22 Polyarteritis nodosa
Non-CDL 23 Scleroderma
Non-CDL 24 Sjögren’s disease
Non-CDL 25 Trigeminal neuralgia
Non-CDL 26 Psoriatic arthritis
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