Bestmed Beat 3 Network medical aid plan: 2017

Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB. Pay for maximum 4 children.

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:
Hospital Choice:
  • Netcare Hospitals, or up to R10,000 co-payment if you voluntarily choose another hospital
Specialised Radiology:
Supplementary Services: (Physio, etc)
Transplants:
Co-payments:
  • Scopes: R3,000 co-payment if in private hospital
Alternatives to hospitals:

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • R8,750 per family paid by scheme
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

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Consultations:
  • 12 consults, paid by scheme
Scans:
  • 2 scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • PMBs only, at State hospitals

Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Preventative dentistry: paid by scheme. Includes exam, radiographs, scaling and polishing, fissure sealing and space maintainers
  • Otherwise, from day-to-day benefit
  • Dental and oral surgery: R6,300 per family
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

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Orthodontics:
  • Subject to pre-authorisation
Maxillo Facial Surgery:
  • R10,100 per family paid by scheme

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MEDICATION:
Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 5 conditions covered at 75% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R2,700 per person and R5,450 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • R1,800 per family per year, paid by scheme
On Discharge:
  • 7 days
Notes:

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OPTOMETRY:
Optometry:
  • Consultation: R350
  • Frame: R550
  • Lenses: Single R165 or Bifocal R360 or Multifocal R660
  • Contact lenses: R1,000
  • Refractive surgery: R6,500 per eye
  • Paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • 21 days per person
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:


Out-of-hospital:
  • Paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:

1.1. Hearing Aids:
  • Paid from day-to-day benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit
Dialysis:
HIV:
  • Managed care programme
Emergency Transport: ER24
International Coverage:
Other:
  • Wound care: R2,750 per family, paid by scheme

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:

Pneumonia vaccines:
  • Covered
Back Rehabilitation Programme:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, 18yrs+ every 2 years
Mammogram: No benefit
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

Compare with these plans:
Sub-limits:

    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