In-hospital scheme benefits

Out-of-hospital benefits

• O ut-of-hospital benefits are paid by CareCross at 100% of CareCross tariff and are subject to CareCross protocols unless otherwise stated.

What are the benefits covered by CareCross General Practitioners (GPs)?

• As many consultations as are medically necessary to get you healthy.
• Selected minor trauma treatment, such as stitching of wounds.
• Medicine for acute ailments subject to the CareCross formulary.
• Your GP should inform you of any services that are not part of the CareCross benefits.
• You will be responsible for the payment of any services outside of the CareCross benefits.
• Accounts for services rendered at your chosen CareCross GP will be submitted by your CareCross GP to CareCross on your behalf.

What if I need chronic medicine?
• You will be advised if your request for chronic medicine has been approved.
• If approved, you will be contacted by the CareCross chronic medicine provider to arrange access to your chronic medicines.
• Approved chronic medicines are obtainable from network pharmacies. The CareCross chronic medicine provider will assist you with selecting a pharmacy convenient for you.
• Note that most chronic medicines may only be collected once per month.
• It will be necessary for you to visit your CareCross GP to renew your chronic script at least every 6 months.

What is over-the-counter (OTC) medicine and where do I get it?
• Over-the-counter (OTC) medicine is available for self-treatment, for example, if you have a cold and you need to buy medicine without seeing your CareCross GP.
• Benefit is limited to 3 events per beneficiary or a maximum of 5 events per family per year.
• Subject to CareCross OTC medicine formulary and medicine being obtained from MediKredit-enabled pharmacies.
• Subject to reference pricing and Scheme exclusions.

What are my dental benefits?
• Dental benefits are obtainable from a CareCross network dentist.
• The dental benefits are for basic dentistry only and are subject to clinical protocols and an approved tariff list.
• Benefits are limited to primary extractions, fillings, scaling and polishing as well as emergency pain relief.
• Dentures: One set of acrylic dentures is covered per family every 24 months. There is a co-payment of 20% of the total fees which the member must pay directly to the dentist. This benefit is paid according to a list of approved codes and is only available to patients over the age of 21. Pre-authorisation is required.
• Root canal treatment, crowns and other specialised dentistry are not covered.
• Please contact CareCross to confirm which benefits are covered.

What cover do I have for optometry?
• To qualify for the optical benefits, you need to consult a CareCross network optometrist.
• The CareCross benefit covers an optical test, a basic frame from a selected range of frames, with white standard mono- or bifocal lenses; or contact lenses to the value of R400. If you choose a frame outside of the selected range of frames, CareCross will pay R150 towards this frame. You will have to pay the balance of the frame directly to the optometrist.
• Kindly note that any additional services such as tinting etc. are not covered under this benefit. You will have to pay these services yourself.
• Eye test is limited to one test be beneficiary per annum.
• The optical benefit is available per beneficiary, every 24 months.

What about blood tests (pathology)?
• Basic blood tests are only covered if requested by your CareCross GP according to an approved tariff list.
• Your CareCross GP has a list of approved tests and will advise you if the required tests are covered by CareCross.
• Your CareCross GP may draw the blood specimen himself or he may refer you to the closest pathology laboratory to have the tests done. You will need to take the completed yellow CareCross referral form with you to the pathology laboratory.

What if I need X-rays (radiology)?
• The CareCross benefits cover a list of X-rays that may be performed by a radiologist, if referred by your CareCross GP.
• Your CareCross GP will advise you whether or not the required X-ray is covered.
• Your CareCross GP will complete a yellow CareCross referral form for the radiologist indicating the type of X-ray to be performed.
• Your GP will refer you to the closest Radiology practice to have the X-ray performed.

Preventative Care Benefits

• Paid by Bestmed unless otherwise stated.

Other Benefits

26 CDL chronic conditions

• 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

Wellness management programmes

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

• Are HIV positive or have AIDS
• Are pregnant, 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. You must be registered on the HIV/AIDS Benefit Management Programme in order to receive the following spectrum of benefits:

• Advice and counselling from the HIV helpline.
• Regular blood tests to monitor disease progression and to measure response to treatment.                         
• Medication and anti-retrovirals (medicine
  to fight the virus).
• Where a pregnant mother is HIV positive, medication is provided to enable her to have a natural delivery. Medication (known as post-exposure prophylaxis) 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 pregnant mommies throughout their pregnancy.
A dedicated 24-hour emergency line with trained medical personnel can guide members through those sudden and unexpected occurrences during pregnancy.
If a mother 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.

BESTMED 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 these 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
• Biological and selected high cost medicine.
• Surgical dentistry
• External prosthesis
• Specialised dentistry
• Supplementary services out of hospital
• Rehabilitation after trauma

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 (to be found at www.bestmed.co.za under the individual benefit guide annexure).
• 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).

GENERAL CONDITIONS OF THE BENEFIT OPTION

• This option is a network benefit option which means that a third party provider is contracted to provide primary healthcare services/day-to-day services to members through CareCross accredited providers and Preferred Specialist providers. Members may only visit service providers registered on the CareCross National Network.
• A Hospital network shall apply for all in-hospital services and benefits
• The Scheme/CareCross benefits on accounts properly submitted in terms of rule 15 shall be granted as shown in each paragraph hereunder, and the member shall be liable for the difference between Scheme tariff or contracted tariff and the full amount of the account.

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