In-Hospital Benefits

Out-of-Hospital Benefits

Medicine

• All benefits below are subject to pre-authorisation, formularies, funding guidelines and MRP.
• For a list of all chronic conditions, please refer to our website at www.bestmed.co.za

Bestmed’s CDL chronic programme is run by qualified pharmacists and clinical staff who ensure that appropriate, cost-effective and quality treatment is provided to members in terms of the Scheme Rules and Benefits.

• Apply if you are diagnosed with a chronic condition and will need treatment on an ongoing basis.
• for more information on how to apply click here (link to current PBM section, very informative or Call 086 000 2378   The medicine listed in the formulary for CDL chronic condition medication will be paid at 100%.
• You must obtain pre-authorisation for all prescribed medicine by contacting 086 000 2378, faxing 012 472 6760 or e-mailing medicine@bestmed.co.za

Prescribed medicine will be reimbursed under the following conditions:

• Where medicines have generic alternatives registered with the Medicines Control Council of South Africa, Bestmed will pay for the generic medicine up to the Mediscor Reference Price (MRP) for the active ingredient.
  
• The benefit amount for prescribed medicine will be calculated at the Single Exit Price (SEP) plus the dispensing fee (as determined by Bestmed) plus Value Added Tax (VAT), if applicable.
• You may be required to obtain your medicine from a Designated Service Provider (DSP).

26 CDL chronic benefit conditions

Chronic medicine for Chronic Disease List (CDL) conditions
Medicine listed in the formulary for the following 26 chronic conditions will be paid for in full by Bestmed provided you obtain pre-authorisation. Where non-formulary medicine is prescribed, there will be a 35% co-payment which you must pay.

• Addison’s Disease
• Asthma
• Bipolar Mood Disorder
• Bronchiectasis
• Cardiac Failure
• Cardiomyopathy
• Chronic Obstructive Pulmonary Disease
• Chronic Renal Disease
• Coronary Artery Disease
• Crohn’s Disease
• Diabetes Insipidus
• Diabetes Mellitus Type 1
• Diabetes Mellitus Type 2
• Dysrhythmias
• Epilepsy
• Glaucoma
• Haemophilia
• Hyperlipidaemia
• Hypertension
• Hypothyroidism
• Multiple Sclerosis
• Parkinson’s Disease
• Rheumatoid Arthritis
• Schizophrenia
• Systemic Lupus Erythematosu
• Ulcerative Colitis

Wellness management programmes

These programmes are aimed at managing your wellbeing and treatment if for example, you:

• Are HIV positive or have AIDS
• Have cancer etc.

You need to register on the relevant programme/s in order to receive the benefits.
HIV/AIDS benefit management programme
Bestmed covers counselling and testing for members who want to confirm their HIV status.
If you are HIV positive, in order to receive benefits you must be registered on the Benefit Management Programme. These benefits include:

• Advice and counselling from the HIV helpline.
• Regular blood tests to monitor disease progression and to measure response to treatment.
• Medication and anti-retrovirals.
• Where a pregnant mother is HIV positive, medication is provided to enable her to have a natural delivery. Medication is also given to the new born baby to reduce the chances of infection.

The treatment programme covered by Bestmed is based on the HIV/AIDS funding guideline and approved treatment depends on the member’s clinical results. The stage of the disease and the results of blood tests determine what treatment will be covered and how the member must be monitored.
Full details of this programme and the benefits offered will be provided to members who register. You can also find more info here (hyperlink this to the HIV section) or you can contact 011 251 9400.
Oncology benefit management programme
You must be registered on the Oncology Programme in order to receive benefits. Broadly, the programme offers:

• Access to additional benefits and services that form part of the treatment protocol.
• Oncology treatment that includes chemotherapy, radiation therapy, certain pathology, certain radiology and certain consultations.

Note:

• All services must be pre-authorised by Bestmed.
• Preferred providers may be appointed by Bestmed.
• The services must fall within Bestmed’s funding protocol.

You can also find more info here (Hyperlink to Oncology section) or you can contact 012 472 6254.

GENERAL EXCLUSIONS APPLICABLE TO ALL BENEFIT OPTIONS (PMB’S NOT APPLICABLE)

• All travel expenses for doctors and patients.
• Medical aids, orthopaedic, surgical and medical appliances, except for those defined in Annexure B.1 to B.9 (to be found at www.bestmed.co.za under the individual benefit guide annexure).
• Reports, examinations and tests requested for emigration, immigration, visas, insurance policies, employment, admission to schools and universities, court medical reports, muscle-function tests, fitness examinations and tests, adoption of children and retirement because of ill health.
• Any operations, treatment and procedures for non-functional or cosmetic purposes.
• Accounts for services rendered by persons not registered with the Health Professions Council of South Africa, Associated Health Service Professions Board or any other similar Healthcare body in the country where the service was rendered.
• Accounts in respect of:
  • All costs of whatsoever nature incurred for treatment of sickness conditions or injuries sustained by a member or a dependant and for which any other party is liable. The member is however entitled to such benefits as would have applied under normal conditions, provided that on receipt of payment in respect of medical expenses, the member will reimburse the Scheme any money paid out in respect of this benefit by the Scheme.
  • Obesity.
  • Appliances and medication to prevent injuries during sports and recreational activities.
  • Injuries arising from illegal actions on the basis of which the member or his dependants took part in a criminal offence.
  • Appointments not kept by members.
• Accommodation in an old-age home or institution providing general care and nursing services to persons, e.g. the infirm aged and chronically sick patients, or similar institutions.
• Examinations, tests and treatment of impotence and of infertility or artificial insemination of a person within or outside the human body as defined in the Human Tissues Act, 1983 (Act 65 of 1983).  In the case of artificial insemination, Bestmed shall not make any contribution in respect of the preparatory expenses, i.e. pre-insemination expenses or insemination outside the female body.
• Costs in excess of the annual maximum benefits to which the member is entitled under Bestmed’s rules.
• Any costs in respect of conditions specifically excluded from benefits because of a waiting period at admission or registration of the member and his dependants with Bestmed.
• The costs of holidays for recuperation purposes, accommodation in spa’s, health resorts and places of rest even if prescribed by a treating provider.
• HIV, AIDS and other sexually contagious diseases:  Provided that
  • Services in a public hospital shall be paid, limited to the minimum benefits provided for in Regulation 8 of the regulations in terms of the Medical Schemes Act (No. 131 of 1998) and Annexure D1 of this Rules;  and
  • The member or his dependants shall furnish clinical evidence of their HIV/AIDS status to the Medical Advisor of Bestmed.
• Costs arising from a person’s association with the official armed forces for which he is covered.
• Benefits not referred to in this Schedule or services not rendered in terms of accepted protocol or are not aimed at the treatment of an actual or supposed condition or deficiency, disadvantaging or endangering essential bodily functions.
• Mammary surgery except where this is related to carcinoma, tumours and abscesses.
• Refractive surgery except where the dioptric myopia value is any figure of -5 or and above and hyperopia with figure +3 dioptre and astigmatism -2,5 and above:  Pre-authorisation shall apply.
• Any cost charged by a service provider for medical motivations or prior motivations as stipulated by these Rules.
• Costs arising from lost or damaged devices, apparatus, spectacles or contact lenses.
• Psychometric tests.
• Injuries during participation in riots, civil unrest or public disorder, war, invasion, any act of foreign enemies, hostilities, warlike operations or civil war.
• Exclusions relating to oral and dental benefits
  • The cost of gold, metal or other inlays in a denture and/or crown.
  • Bleaching of vital teeth.
  • Lingual orthodontics.
  • Procedures considered by Bestmed as cosmetic or of a cosmetic approach where alternative procedures exist.
  • Items indicated in the Dental Schedule as “by arrangement” or “N/A”.
  • Procedures requiring prior authorisation for which no authorisation was applied for.
  • Sunglasses

The following benefits are not applicable:

1. Any out-of-hospital services for members (day-to-day benefits), including all non-CDL chronic medicine, all acute medicine and over-the-counter medicine.
2. Biological and selected high cost medicine.
3. Rehabilitation after trauma.
4. Orthopaedic and surgical appliances during hospitalisation.

MEDICINE EXCLUSIONS

1. Preparations for the specific treatment of obesity, including dietary supplements
2. Patent and household remedies
3. Nutritional supplements (including patent and baby foods)
4. Medicines used specifically to treat infertility
5. Aphrodisiacs
6. Sun-screening agents (medicated or otherwise)
7. All soaps and shampoos (medicated or otherwise)
8. Cosmetic substances
9. Anti-habit substances
10. Anabolic steroids
11. Tonics, stimulants, biological substances, vitamins, minerals and vitamin/mineral combinations unless proven medical indications can be submitted:  Provided that Bestmed will contribute on the following:
    1. Prenatal medicine.
12. Unregistered medicines will not be considered for benefits until such time that it is registered by the Medicines Control Council.
13. Unregistered indications or “off label” use of medicines will not be considered for benefits.

LIMITATION OF BENEFITS

1. The maximum benefits to which a member and his dependants are entitled in any financial year are limited as set out in Annexure B1 to B9 (to be found at www.bestmed.co.za under the individual benefit guide annexure).
2. Members admitted during the course of a financial year are entitled to the benefits adjusted in proportion to the period of membership calculated from the date of admission to the end of the particular financial year.
3. Unless otherwise decided by the Board of Trustees, benefits in respect of medicines obtained on a prescription are limited to one month’s supply for every such prescription or repeat thereof (to be found at www.bestmed.co.za under the individual benefit guide annexure).

GENERAL CONDITIONS OF THE BENEFIT OPTION

• The Scheme’s benefits on accounts properly lodged in terms of rule 15 shall be granted as shown in each paragraph hereunder, and the member shall be liable for the difference between the Scheme’s benefits and the full amount of the account.
• No benefits shall be granted on accounts reaching the Scheme after the last day of the fourth month following the date on which the service was rendered.
• Where an account has been paid by the member in cash, such specified account plus proof of payment must be submitted to the Scheme before the last day of the fourth month following the date on which the service was rendered. The Scheme will then refund the member the applicable benefit amount.
  

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