Pace4

You are a discerning family who may have above average medical costs. You need the comfort of extensive benefits for preventative (such as PSA, PAP smears, and bone densitometry) day-to-day medical care, maximum cover for chronic conditions and hospital expenses. In addition, an individual medical savings account, which offers further payment flexibility, is also available. With the exclusivity that Pace4 offers, you have the greatest cover with complete peace of mind.

Benefits

In-hospital scheme benefits

• All in-hospital benefits referred to in the section below require pre-authorisation.
• Clinical funding protocols apply.
• Please contact 0800 22 0106 to obtain a pre-authorisation number.

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 R20 400 per beneficiary.
Consultations and procedures	100% Scheme tariff.
Surgical procedures and anaesthetics	100% Scheme tariff.
Organ transplants	100% Scheme tariff.
Dentistry: Maxillo-facial surgery strictly related to certain conditions	100% Scheme tariff.
Prosthesis – Internal (Subject to preferred provider, otherwise limits and co-payments apply)	100% of cost. Limited to R88 200 per family. Sub-limits per beneficiary: • Vascular R31 200 • Spinal R31 200 • Artificial disk, single-level based, R14 000 • Drug eluting stents R14 000 • Mesh R12 400 • Gynaecology/Urology R10 200 • Lens implants R11 300 per lens • Joint replacements: - Hip replacement and other major joints R37 600 - Knee prosthesis R43 500 - Minor joints R14 000
Prosthesis – External	R20 400 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 (Preferred provider)	Oncology Programme. 100% Scheme tariff.
Peritoneal Dialysis and Haemodialysis	100% Scheme tariff.
Confinements	100% Scheme tariff.
Midwife-assisted births	100% Scheme tariff.
Supplementary services	100% Scheme tariff.
Alternatives to hospitalisation	100% Scheme tariff.
Emergency Evacuation	100% of cost. Rendered and pre-authorised by ER24.

Out-of-hospital benefits

• The following out-of-hospital benefits are paid at 100% of the Scheme tariff.
• Subject to sub-limits and benefits available in the day-to-day overall limit.
• All day-to-day expenses will firstly be paid from the overall day-to-day benefit at 100% of Scheme tariff.
• Once this benefit is depleted, the member may request payment from the individual medical savings account (IMSA).
• The annual IMSA will only be used for day-to day medical expenses and will not be used for preventative care benefit expenses or in-hospital expenses.
• The member may request payment from the IMSA for benefits after sub-limits have been reached, or when co-payments occur.
• Unused funds at the end of a financial year will remain the property of the member and will accumulate to the next financial year.

Medical event	Scheme benefit
Day-to-day overall limits	M = R24 700, M1+ = R39 800.
GP and Specialist consultations	Limited to M = R3 700, M1+ = R6 000. (Subject to day-to-day overall limit)
Basic and Specialised Dentistry	Limited to M = R7 300, M1+ = R12 400. (Subject to day-to-day overall limit)).
Medical aids, apparatus and appliances	Limited to R22 000 per family. Sub-limit on wheel chairs = R9 100 per family per 48 months. Sub-limit on hearing aids = R21 500 per family per year.
Supplementary Services	Limited to M = R3 700, M1+ = R7 300. (Subject to day-to-day overall limit)
Wound care benefit (incl. dressings and negative pressure wound therapy (NPWT) treatment and related nursing services - out of hospital)	Limited to R9 100 per family. (Subject to day-to-day overall limit)
Optometry services, frames and other (lenses)	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 R290 • Frame R1000 • Single-vision lenses R150 OR • Bifocal lenses R325 OR • Multifocal lenses R600 OR • Contact lenses R1 710
Diagnostic imaging and Pathology	Limited to M = R3 700, M1+ = R7 300. (Subject to day-to-day overall limit)
Maternity benefits	Combined limit, included in GP and specialist benefits.
Specialised diagnostic imaging	Subject to pre-authorisation. MRI/CT scans: Maximum of three scans per beneficiary. PET scan: One scan per beneficiary.
Rehabilitation services after trauma	100% Scheme tariff. Subject to pre-authorisation and protocols.

*This means that there will be no co-payment but limited to only those products and services negotiated by PPN and only those frames specified by PPN.

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.

Benefit description	Scheme benefit
Non-CDL chronic medicine Please note that CDL and non-CDL chronic medication costs will be paid from the non-CDL limit first. Thereafter, CDL chronic medication costs continue being paid by the Scheme.	45 non-CDL conditions are covered at 85% of the Scheme tariff. Limited to M = R17 200, M1+ = R34 400. Co-payment of 20% for non-formulary medicine.
CDL chronic medicine Please note that CDL and non-CDL chronic medication costs will be paid from the non-CDL limit first. Thereafter, CDL chronic medication costs continue being paid by the Scheme..	100% of Scheme tariff. Co-payment of 20% for non-formulary medicine.
Biological medicine	Limited to R322 500 per beneficiary.
Acute medicine	Limited to M = R5 800, M1+ = R9 100. A 10% co-payment is payable. (Subject to day-to-day overall annual limit)
Over-the-counter medicine	Limited to R1 100 per family. (Subject to day-to-day acute medicine limit)

Preventative Care

Benefit type	Gender and age group	Quantity and frequency	Benefit criteria
Influenza vaccine	All ages.	One per beneficiary per year.	Applicable to all active members and beneficiaries.
Pneumonia Programme	Children < 2 yrs. High risk adult group.	Once every 60 months.	Funding for children < 2 years: Parents to contact the Scheme in advance to pre-arrange funding prior to obtaining the vaccine. Funding for adults: The Scheme will identify certain high risk individuals who will be advised to be immunised.
Paediatric immunisations	Funding for all paediatric vaccines according to the state-recommended programme for babies and children.
Female Contraceptives	All females of child bearing age.	Quantity and frequency depending on product up to the maximum allowed amount. Mirena Device – one device every 60 months.	Limited to R1 400 per family per year. Includes all items classified in category of contraceptives.
Back rehabilitation programme Provided by Documentation Based Care (DBC)	All ages.	Up to 6 weeks treatment plan as per approval.	Applicable to beneficiaries that have serious spinal or back problems and may require surgery. The Scheme identifies appropriate participants for evaluation at the DBC Centre. Based on the outcomes of the evaluation, a rehabilitation treatment plan is drawn up and initiated which lasts approximately 6 weeks.
HIB titre immunisation	Children 5 years and younger.	One vaccine at 6, 10 and 14 weeks after birth. One 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 45 years and older.	Once every 24 months.
PAP smear	Females 45 years and older.	Once per year.	Can be done at a gynaecologist or GP. Consultation paid from the consultation benefit.
PSA test (Prostate Specific Antigen)	Males 45 years and older.	Once per year.	To be done at urologist. Urologist consultation paid from the consultation benefit.
HPV vaccinations	Girls 9-13 years.	Three vaccinations per beneficiary.	GSK’s Cervarix vaccinations will be funded at MRP.
Bone densitometry	All beneficiaries, 45 years and older.	Once every 24 months.
Biometric screening: • Glucose test (finger prick test) • Cholesterol test (finger prick test) • Blood Pressure. • Body Mass Index (BMI)	All beneficiaries, 10 years and older.	One per beneficiary per year.	All beneficiaries, 10 years and older, have access to one biometric benefit package from selected pharmacies (Dis-Chem, Clicks, Script Savers and Pick n Pay). This will be reimbursed from the Scheme risk benefit and will not impact your day-to-day benefits.

Preventative dentistry

Benefit type	Age	Frequency
General full mouth examination by a general dentist (incl.gloves and use of sterile equipment for this 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.	2 x 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.

CDL Chronic Benefits

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.
Call 086 000 2378 for more information on how to apply or go to www.bestmed.co.za
The medicine listed in the formulary for CDL chronic condition medication will be paid at 100%.
Co-payment of 20% for non-formulary medicines.
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 conditions
Chronic medicine for Chronic Disease List (CDL) conditions
The reference price for medicine listed in the Bestmed formulary for the following 26 chronic conditions will be paid provided you obtain pre-authorisation.

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 Erythematosus
Ulcerative Colitis

45 Non-CDL conditions

Chronic medicine for Chronic Disease List (CDL) conditions
The reference price for medicine listed in the Bestmed formulary for the following 45 non-CDL conditions will be paid at 85% of the Bestmed tariff.

Acne – severe
Allergic rhinitis
Alzheimer’s Disease
Ankylosing spondylitis
Aplastic anaemia
Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD)
Benign Prostatic Hypertrophy
Chronic anaemia
Collagen Disease
Cushing’s Disease
Cystic Fibrosis
Dermatomyositis
Eczema
Endometriosis
Female menopause
Fibrosing alveolitis
Gastro Oesophageal
Reflux Disease
Gout prophylaxis
Graves Disease
Hyperthyroidism
Hypophyseal adenoma
Hypopituitarism
Idiopathic Thrombocytopenic Purpura
Major depression
Migraine prophylaxis
Motor Neuron Disease
Muscular dystrophy and inherited myopathies
Myasthenia Gravis
Neuropathy
Obsessive Compulsive Disorder
Osteoarthritis
Osteoporosis
Paget’s Disease
Paraplegia/Quadriplegia (medicine to treat)
Polyarteritis nodosa
Polycystic Ovarian Disease
Psoriasis
Psoriatic arthritis
Pulmonary Interstitial Fibrosis
Pulmonary embolism
Scleroderma
Sjogren’s Disease
Stroke
Trigeminal neuralgia
Urinary incontinence

Contributions

Wellness

Wellness Management Programmes

These programmes are aimed at managing your well-being and treatment if for example, you:

Are HIV positive or have AIDS
Are pregnant
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 on the Bestmed website under ‘Managed care’ or you can contact
011 251 9400.

BestBaby

This programme has been designed to support expecting mommies throughout their pregnancy. A dedicated 24-hour emergency line with trained medical personnel can guide you through those sudden and unexpected moments during pregnancy.
If a mom is regarded as a clinically high risk, her pregnancy will be monitored more closely by having regular blood tests and blood pressure assessments.
Full details of this programme and the benefits offered will be provided to members who register.
You can also find more information on the Bestmed website under ‘Managed care’ or you can contact 011 704 0072.

Exclusions

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
Non PMB complications for breast reduction.

MEDICINE EXCLUSIONS (EXCLUDING MINIMUM BENEFITS)

Preparations for the specific treatment of obesity, including dietary supplements.
Patent and household remedies.
Nutritional supplements (including patent and baby foods).
Medicines used specifically to treat infertility.
Aphrodisiacs.
Sun-screening agents (medicated or otherwise).
All soaps and shampoos (medicated or otherwise).
Cosmetic substances.
Anti-habit substances.
Anabolic steroids.
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:
- Prenatal medicine.
- Unregistered medicines will not be considered for benefits until such time that it is registered by the Medicines Control Council.
- Unregistered indications or “off label” use of medicines will not be considered for benefits.

LIMITATION OF BENEFITS

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.
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.
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).