Bestmed Pace 1 medical aid plan: 2017

Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund 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, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

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Hospital Choice:
  • Unlimited
Specialised Radiology:
Supplementary Services: (Physio, etc)
Transplants:
Co-payments: n/a
Alternatives to hospitals:

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Limited to M =R1,750 and M1+ =R3,550
  • Paid from day-to-day benefit
  • Shared with specialist benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

Compare with these plans:

Specialists consultations:
  • Shared with GP benefits, see above
Pathology:
  • Limited to M =R2,550 and M1+ =R5,100
  • Paid from day-to-day benefit
  • Shared with radiology benefit
General radiology:
  • Limited to M =R2,550 and M1+ =R5,100
  • Paid from day-to-day benefit
  • Shared with pathology benefit
Specialised radiology:
  • R11,450 per family, paid by scheme
Supplementary Services: (Physio, etc)
  • Limited to M =R3,450 and M1+ =R7,150
  • Paid from day-to-day benefit
  • Shared with radiology benefit

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

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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):
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, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

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, paid from day-to-day benefit first
  • Once savings are depleted, you are limited to M= R3,150 and M1+ =R6,400 per year in total
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

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Orthodontics:
  • Subject to pre-authorisation
Maxillo Facial Surgery:
  • R10,200 per family
  • Other dental/oral surgery: R6,300 per family

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MEDICATION:
Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 7 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R5,200 per person and R10,450 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

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Acute (presrcibed) medication:
  • Limited to M1= R1,850 and M1+ =R3,800
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit, limited to R525
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: R7,000 per eye
  • Paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • 21 days per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

Compare with these plans:


Out-of-hospital:
  • Limited to M =R1,750 and M1+ =R3,550
  • Paid from day-to-day benefit
  • Shared with GP and specialist benefit

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OTHER BENEFITS:
General Appliances:
  • R9,000 per family
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
HIV:
  • Managed care programme
Emergency Transport: ER24
International Coverage:
Other:
  • Wound care: R2,850 per family, from day-to-day benefit
  • Rehab after trauma: vested savings

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

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:
  • Covered
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

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