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Find the answers to your most burning questions about medical aid right here!
Yes, only if the member is already registered on the Bestmed system for chronic medicine. If not, the doctor will need to complete the chronic application form with the relevant supporting documentation, where needed.
When doctors call in and complete a telephonic prescription with one of Bestmed’s pharmacists, it is seen as a legal prescription as the call is recorded. This will not be applicable to pharmacists calling from a dispensing pharmacy as they are not the prescriber.
Yes, medicine can be delivered to you by any postal pharmacy of your choice. Please refer to the preferred providers list to avoid any dispensing fee co-payments.
| Benefit Option | Beat1 | Beat2 | Beat3 | Beat3 Plus | Beat4 | Pace1 | Pace2 | Pace3 | Pace4 | Rhythm1 | Rhythm2 |
| CDL/PMB Form | No co-payment | ||||||||||
| CDL/PMB Non-Formulary | 30% | 30% | 30% | 30% | 20% | 25% | 20% | 15% | 10% | 30% | 30% |
| Non-CDL Formulary | N/A | N/A | 20% | 20% | 10% | 10% | 10% | 10% | 0% | N/A | N/A |
| Non-CDL Non-Formulary | N/A | N/A | 30% | 30% | 20% | 25% | 20% | 15% | 10% | N/A | N/A |
When do co-payments apply?
Yes, but it depends on the chosen option, as well as the condition. Biological medicines are categorised as PMB biologicals and non-PMB biologicals. Approved PMB biological and non-PMB biological medicine costs will be paid from the biological limit first, on the options that have a biological limit (Pace2, Pace3 and Pace4). Once this limit is depleted, only PMB biological medicine costs will continue to be paid, unlimited, from Scheme risk.
You and the treating doctor will be required to complete a chronic medicine application form. It is advisable that you present the treating doctor with a copy of the medicine formulary as it applies to the specific Bestmed Scheme option and the specific chronic condition.
Fax: 012 472 6760
Email: medicine@bestmed.co.za
On the Bestmed App
Approved CDL, non-CDL and PMB medicine costs will be paid from the non-CDL chronic medicine limit first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
Note:
Once a complete application is received by Bestmed, processing takes approximately two to three working days.
Chronic medicine claims can be submitted every 24 days.
You should only submit your prescription to Bestmed if your medicine has changed or if your authorisation is about to expire. However, your pharmacy will require a new repeat prescription every six months in order to dispense your medicine.
Approval conditions
Bestmed can grant approval for a member to claim for an advanced supply of medicine in the following instances:
Please note that Bestmed will not grant approval for an advanced supply of medicine when members are travelling within the borders of South Africa.
Approval process
The process for approval takes up to five working days to complete. Please ensure that all required documentation is received together and timeously before the requested collection date.
Please attach the following to the completed form:
This information can be emailed to medicine@bestmed.co.za or faxed to 012 472 760.
No. To access the chronic benefit, pre-authorisation is compulsory. Thus, it is the member’s responsibility to apply for chronic benefits.
A generic medicine contains identical amounts of the same active ingredient in the same strength and in the same dosage form as the original medicine. Generic medicines are approved by the South African Health Products Regulatory Authority (SAHPRA) and must have the same quality and produce an equivalent effect in the body as the original medicine. Benefits of using generic medicines:
PMBs is a set of minimum benefits which, by law, must be provided to all medical scheme members and include the provision of diagnosis, treatment and costs of ongoing care.
Benefits will only be granted from the date the fully completed application/prescription is received. No retrospective authorisations will be granted.
Should you prefer to use the original product, Bestmed will only reimburse the claim up to the reference price amount. You will be responsible for the difference in price payable to the provider.
A biosimilar is a biologic medical product that is almost an identical copy of an original product that is manufactured by a different company.
The CDL is a list of chronic illnesses or conditions for which a scheme must provide cover for the medicine and treatment. These are conditions such as hypertension, asthma and diabetes.
A biological is a substance that is made from a living organism or its products and is used in the prevention, diagnosis or treatment of diseases and chronic conditions.
The Mediscor Reference Price (MRP) is a reference pricing model applicable to all medicines with generic equivalents or biosimilars. MRP sets the maximum reimbursable price for generically similar or biosimilar products. This means that if you opt to use a medicine above MRP, you will have to pay the difference between the selected medicine and that of MRP. Reference pricing is applicable to all medicines, including formulary and non-formulary chronic medicines, as well as acute and over-the-counter (OTC) medicines.
One month prior to the date your medicine authorisation expires, you must submit a copy of your latest prescription, including the ICD-10 code, with your member number to medicine@bestmed.co.za or fax 012 472 6760.
Please submit your renewed script timeously to Bestmed to ensure correct payment of claims as no retrospective authorisations will be granted.
Additional information is required with the prescription for:
Send a copy of the new prescription (please ensure the diagnosis codes are included on the prescription) to medicine@bestmed.co.za or fax 012 472 6760. Please submit your renewed script timeously to Bestmed to ensure correct payment of claims as no retrospective authorisations will be granted.
| CONDITION | SPECIFIC REQUIREMENT |
| Addison disease | Prescription required from endocrinologist or physician |
| Ankylosing spondylitis |
Prescription required from a rheumatologist or physician |
| Anaemia | Most recent laboratory report required |
| Alzheimer disease | Mini-mental state examination (MMSE) required together with a prescription |
| Autism | Prescription required from a paediatrician, paediatric neurologist or child psychiatrist |
| Blepharospasm | Prescription required from a neurologist together with a motivation |
| Bronchiectasis and pulmonary interstitial fibrosis | Prescription required from a pulmonologist or physician, or a paediatrician (in the case of a child) |
| Collagen disease/scleroderma and Paget disease | Prescription required from a physician |
| Crohn disease and ulcerative colitis | Prescription required from a gastroenterologist or physician together with motivation and supporting documentation |
| Chronic obstructive pulmonary disease (COPD) | Lung function test (LFT) report is required, which includes the FEV1/FVC and FEV1 post bronchodilator use. |
| Chronic renal disease | Application form must be completed by a nephrologist or physician. Attach supporting laboratory reports. |
| Diabetes mellitus (Type 2) |
Submit HbA1c blood test results and/or fasting blood glucose results, pre-treatment value and current values |
| Diabetes insipidus | Application form must be completed by an endocrinologist or physician |
| Epilepsy | EEG report must be submitted with the application or a prescription from the neurologist is required or a paediatrician (in the case of a child) |
| Haemophilia |
Prescription required from physician. |
| Hyperlipidaemia | Lipogram results required |
| Multiple sclerosis |
Prescription required from a neurologist together with supporting scans for initial applications.
|
| Osteoporosis |
Most recent bone mineral density (BMD) test results required |
| Oxygen therapy |
For initial applications:
|
| Polyarteritis nodosa/psoriatic arthritis and Sjogren syndrome | Application form must be completed by a rheumatologist or physician |
| Psychiatric conditions | Prescription is required from a psychiatrist. A family practitioner may prescribe the following active ingredients: fluoxetine, citalopram, escitalopram and tricyclic anti-depressants |
| Rheumatoid arthritis | Prescription required from a rheumatologist. A family practitioner may also submit a prescription together with the pathology report |
These are pharmacies that have committed to providing cost-effective medicines at competitive dispensing fees which are capped at a lower level than non-network pharmacies. Any pharmacy that charges a dispensing fee of not more than 33% with a maximum of R33 (excl. VAT), and charges no additional administration fees, can be regarded as a preferred provider. Bestmed has negotiated providers, which will charge a dispensing fee the same as, or lower than the Bestmed fee structure. You are advised to obtain your medicine from one of these preferred providers to avoid any dispensing fee co-payments.
The reference price is reviewed and updated on a regular basis, and is dependent on the availability of generic medicines, as well as new generics entering the market. Thus, the change in reference price can affect the co-payment amount.
Bestmed applies protocols and funding guidelines in their authorisation process. Should your requested treatment fall outside of these funding guidelines, it will not be approved.
An MSA is a benefit account established in the name of the principal member concerned
The MSA is calculated using a fixed percentage of the total contribution.
Medical expenses for out-of-hospital services are paid from an MSA if available on the chosen option.
These funds are available from the beginning of the year or prorated if the Scheme was joined during the year.
No, not all plan options have a Medical Savings Account. The Rhythm and Beat1 options do not include a Medical Savings Account.
You first utilise the Medical Savings Account. Once it is depleted, you will have access to your day-to-day benefits on specific plan options.
On Beat4, Pace1, Pace2 and Pace3 your day-to-day benefits will become available.
No, the MSA does not fund co-payments.
No, you don’t lose it. It becomes a part of the following year's savings or will be added to your vested savings, depending on your benefit option.
Yes. The Scheme allocates the net interest received on Medical Savings Account invested funds to members with positive savings balances.
The money will be transferred for you to use the following year. If you resign your membership with Bestmed and choose not to join another scheme, or if you join a scheme without a savings option, the money will be paid to you. If you join a scheme with a savings account, the money will be transferred into the new scheme's medical savings account if a principal member joins another scheme with an MSA option.
Vested savings are accumulated savings from previous years.
Members may request payment of services such as co-payments, certain excluded medicine items and fees above Scheme tariff to be paid from their vested savings, depending on their benefit option.
Yes. Members may apply to the Scheme to use their vested savings to pay for additional benefits, such as tinted glasses.
Costs relating to PMB services, or the self-payment gap, cannot be paid from vested savings.
Members can give permission to pay for claims from the vested savings account. Some claims are automatically paid from vested savings.
The principal member will receive the balance of funds, including interest earned.
This is the portion of a claim payable by the member directly to the service provider. This co-payment cannot be paid automatically from the available savings account or vested savings account.
Please note that according to the Council for Medical Schemes (CMS), co-payments may not be deducted from your savings account or vested savings account or reimbursed to you. The co–payment percentage varies according to the different benefit options. The table below highlights the different co–payments applicable per Scheme option for the CDL, PMB and non–CDL conditions:
| BENEFIT | Non-formulary co-payment for CDL and PMB medicine | Formulary co-payment for Non-CDL conditions | Non-formulary co-payment for Non-CDL conditions |
| BEAT1 / BEAT1 N | 30% | N/A | N/A |
| BEAT2 / BEAT2 N | 40% |
N/A |
N/A |
| BEAT3 / BEAT3 N | 40% | 20% |
35% |
| BEAT4 | 30% | 10% | 25% |
| PACE 1 | 35% | 10% | 30% |
| PACE 2 | 30% | 10% | 25% |
| PACE 3 | 25% | 10% | 20% |
| PACE4 | 20% |
10% | 15% |
| RHYTHM1 | 30% | N/A | N/A |
| RHYTHM2 | 30% | N/A |
N/A |
A biosimilar is a biologic medical product that is almost an identical copy of an original product that is manufactured by a different company.
Bestmed has contracted with various Designated Service Providers (DSPs) to provide rehabilitation for alcohol and substance abuse. Please note that this benefit is subject to pre-authorisation and will be funded up to a maximum limit or a duration of 21 days whichever is depleted first.
The back and neck preventative programme’s goal is to assist members with chronic back and/or neck pain and to improve the clinical state of the back and/or neck to prevent surgery. Documented Based Care (DBC) and Workability facilities are Bestmed’s contracted healthcare providers for this programme.
The Beat range offers flexible hospital benefits on all Beat options with limited savings to pay for out-of-hospital expenses on some options such as Beat2 and Beat-3, but extensive out-of-hospital cover on Beat4.
Biological and other high-cost medicines are derived from a living source, for example interferon treatment for advanced melanoma.
The Chronic Disease List (CDL) provides cover for the 27 listed chronic conditions for which medical schemes must cover the diagnosis, medical management and medicines as published by the Council for Medical Schemes.
These pharmacies are the preferred providers for rendering HIV/AIDS related services and post-exposure prophylaxis in the case of sexual assault.
Concluding the state of pregnancy, from contractions to birth of the child.
The contracted tariff is the tariff as approved by the Board of Trustees and contractually agreed with service providers.
The quantity and frequency depend on the product up to the maximum allowed amount. Mirena device – 1 device every 5 years. All contraceptive benefits are limited to R2550 per female beneficiary, per year and includes all items classified in the category of female contraceptives.
This is an amount that you need to pay towards a healthcare service which is not covered by the Scheme. The amount can vary by the type of covered healthcare service, place of service or if the amount the service provider charges is higher than the rate the Scheme pays.
Computed tomography. A type of diagnostic imaging, using rotating x-rays and computers to create cross-sectional images of the soft tissues inside your body, bones and blood vessels.
Day-to-day refers to the amounts available for the payment of medical expenses incurred outside the hospital environment.
Specific groups of providers with the Scheme to render specified services at an agreed rate. They are healthcare providers that are considered the preferred choice for members’ healthcare needs specifically related to PMB conditions.
Diabetes is a chronic, lifelong condition that affects your body’s ability to use the energy provided by food. Diabetes mellitus is a chronic disease where the pancreas either does not produce any or enough insulin, which causes an excess of sugar (glucose) in the blood. Insulin is the hormone that assists your body cells to use glucose as energy for it to function properly.
Members who require chronic dialysis for end-stage renal disease can register on the dialysis programme. Depending on clinical and other parameters, the Scheme will consider funding for peritoneal or haemodialysis. Certain medicines, which are used in end-stage renal disease, are only covered when the Scheme funding guidelines are met. Bestmed has appointed National Renal Care (NRC) as designated service provider (DSP) for renal dialysis services for its members on all the benefit options.
If a specific hospital in the DSP hospital network cannot render a specific service, a hospital that can render the service in a 50km radius will be a preferred provider.
This is a network option for which a member can apply for a decreased premium. The member sacrifices freedom of choice, should they apply for this option. This means that the member can make use of certain hospitals and specialists. A member will receive fewer savings if they choose this option. A member can only make use of Life Health Care, NHN, Medi-Clinic Hospitals, as well as specialists that are contracted to these hospitals. Day-to-day benefits remain the same applies on the Beat3 option. An EDO option is applicable on the Beat1, Beat2 and Beat3 options.
Endoscopy is an invasive diagnostic medical procedure that is used to assess the interior surface of an organ by inserting a tube with a camera in the body. Examples: gastroscopy, colonoscopy, cystoscopy.
Bestmed members between the ages of 3 months and 86 years have access to R3 million in international travel cover through Europ Assistance for all destinations excluding the USA. Destinations within the USA have a limit of R500 000 per family. This policy provides cover for up to a maximum of 45 (forty-five) days in the USA and 90 (ninety) days worldwide per trip, irrespective of how many flights are made during the year. It is essential that members familiarise themselves with the policy wording to ensure that they are familiar with all the terms and conditions of the policy.
Medical schemes are entitled to exclude specific services/events e.g., cosmetic surgery, travel costs and examinations for insurance purposes etc.
A formulary is a pre-determined list of medicines that will be covered for the CDL, non-CDL and PMB conditions. These lists of covered medicines vary from option to option. Bestmed makes use of formularies for each condition. These formularies are compiled and maintained by a team of professionals on the basis of evidence-based medicine, considering cost effectiveness and affordability.
Bestmed allows flexibility in terms of every member and dependant’s choice of medicine. If a member chooses to make use of a product that is not on the formulary, a co-payment will be applicable. This co-payment varies between the different benefit options, and forms part of Bestmed’s Scheme Rules.
Commonly known as a general practitioner (GP).
Items utilised towards treating or supporting a bodily function.
A hospital that does not specialise in the treatment of a particular service. A hospital that can render the service in a 50km radius will be a preferred provider.
If a member has a general three-month waiting period, the member is entitled to apply for CDL and PMB chronic benefits.
If a member has a 12-month condition specific exclusion, the member cannot apply or claim for any services relating to that condition for a period of 12 months. The member also cannot apply for or claim for CDL and/ or PMB benefits if it relates to the specific condition.
The locations or geographic area related to a case where there is no hospital that belongs to the specific DSP group hospital. Another hospital will be listed as the preferred hospital.
Means the applicant’s gross monthly income before any deductions. Only applicants whose monthly income is less than the highest income category must provide proof of income. Applies to Rhythm benefit options.
HIV (human immunodeficiency virus) is a sexually transmitted infection. It can also be spread by contact with infected blood, or from mother to child during pregnancy, childbirth or breast-feeding. Without medicine it may take years before HIV weakens your immune system to the point where you have full-blown AIDS. Acquired immunodeficiency syndrome (AIDS) is a chronic, potentially life-threatening condition caused by the human immunodeficiency virus (HIV). By affecting your immune system, this virus interferes with your body’s ability to fight organisms that cause infection and other diseases.
An ICD-10 code is a diagnosis code, indicating the illness or condition for which treatment is being received and is, therefore, compulsory on all medicine applications and prescriptions.
ICON Managed Care is a provider-driven oncology managed care organisation that represents a significant number of the private practising oncologists in South Africa. The ICON Network comprises of radiotherapy facilities and accredited chemotherapy facilities across South Africa.
Ophthalmic lens enhancements are additional lens technologies that can be added to a standard ophthalmic lens to improve the functionality and/or durability of the lens. Examples are tints, hard coating and anti-flex coating.
Bestmed has appointed LifeSense managed care to host our HIV/AIDS disease management programme. LifeSense has an excellent track record for managing and providing comprehensive management programmes for HIV/AIDS. They have ensured that members on the LifeSense programme remain clinically healthy, lead a productive life and stay active in their community.
The limit is the maximum benefit amount, which is paid for a specific service, apparatus, or appliance.
Member (single)
Member and beneficiaries/dependants
Major medical benefits include hospitalisation, PMB and trauma recovery. Co-payments and sub-limits may be applicable in some cases.
A mammogram is the process of examining a human breast and is used as a diagnostic and a screening tool.
Pregnant members and dependants have access to the Maternity care programme. The programme provides comprehensive information and services and was designed with the needs of expectant parents and their support network in mind.
A generic reference price is a maximum set price a medical Scheme is prepared to pay for a specific generic molecule for a specific dosage. Bestmed uses the (MRP) as its reference. This allows the prescriber and the member a choice if they want to use a specific brand for whichever reason. This means that a member may use the original medicine and pay the difference between the price of the chosen medicine and the applicable reference price (thus pay a generic co-payment). Alternatively, the member can use a generic alternative within the reference price range and pay no generic co-payment.
Magnetic resonance imaging. A type of diagnostic imaging, using a large magnet and computer-generated radio waves to create detailed, cross-sectional images of your internal organs and tissues.
Members requiring chronic dialysis for renal failure can register on the Dialysis programme. Depending on clinical and other parameters, the Scheme will consider funding for peritoneal or hemodialysis. Certain medicines that are used in end-stage renal failure are only covered when the Scheme funding guidelines are met. Bestmed has appointed National Renal Care (NRC) as designated service provider (DSP) for renal dialysis services for members on all the benefit options.
Network options offer benefits to members in collaboration with a medical provider network. In the case of the Rhythm and Beat EDO benefit options, day-to-day services are rendered by a network of general providers registered and contracted with Bestmed.
Contracted providers with the same scheme to render services for specific network options and benefits. Members are restricted to make use of these providers.
Non-CDL conditions are additional chronic conditions which may be covered by the Scheme, depending on the chosen benefit option. It is not compulsory for the Scheme to fund treatment of these conditions. These are conditions such as gout and acne. Refer to the Comparative Guide for the list of conditions covered per option.
Oncology is the branch of medical science dealing with cancer, including the origin, development, diagnosis and treatment of malignant neoplasms of solid organs, non-solid organs and systems in the body.
Medicine that can be obtained from a pharmacy without a prescription, known as self-medication.
This means that benefits for services rendered during a year are subjected to an overall annual maximum benefit amount and various sub-limits, where applicable.
The Pace range offers comprehensive hospital benefits from Scheme benefits, and additional savings and benefits to cover extensive out-of-hospital expenses. The options in this category are Pace1, Pace2, Pace3 and Pace4.
A papanicolaou test (pap smear), also known as a cervical smear, is a quick, painless test used to detect early cell changes in the neck of the womb, which may later progress to cancer.
Per year means from 1 January to 31 December of a year. Should a beneficiary enroll within a financial year, benefit amounts will be pro-rated according to the remaining number of months of the year.
Position emission tomography scan.
PBM is the management of medicine benefits for Bestmed members, while ensuring easy access to medicines for all members. The Bestmed medicine programme is managed by qualified pharmacists supported by clinical staff, who ensure that appropriate, cost-effective and quality treatment is provided to all members according to Scheme rules and defined benefits.
Benefit available per beneficiary is combined and the total benefit is then available to any member of the family.
Pre-authorisation means benefits for a service must be authorised before it is rendered.
PPN will be solely responsible for the optical benefits, claims and payment queries for all our options, excluding Beat1 and 2 options, and as such all calls should be directed to PPN. It is essential that PPN handle the entire process to avoid any confusion by the members.
Prescribed Minimum Benefits (PMBs) are a set of minimum benefits which, by law, must be provided to all medical scheme members and include the provision of diagnosis, treatment and costs of ongoing care.
Preventative care provides for the benefits of selected out-of-hospital services. Benefits will contribute to protecting the good health of members. Preventative care is important in making sure you detect medical conditions early and so that we can ensure the best care for you in this regard. Bestmed offers preventative care, which covers a number of benefits from the Scheme’s risk benefit and not your savings. General and option-specific exclusions may apply to the various options. Please refer to www.bestmed.co.za for more details.
The term is used to refer to scans that are used to diagnose a medical condition.
Nursing at home by a visiting registered nurse and wound dressings provided at home are only considered under specific clinical circumstances, usually in lieu of hospitalisation and funded from the general risk pool. Private nursing/specialised wound care will be considered on an individual basis. These services must be rendered by a registered nurse with the South African Nursing Council and the private nurse must have a BHF practice number to claim for the service provided.
Aimed at the recovery of impeded vital functions immediately after trauma, such as stroke or heart attack.
The Rhythm range offers full hospital benefits with out-of-hospital benefits provided by designated network providers only. This range has two options: Rhythm1 and Rhythm 2.
The savings account contribution is a fixed monthly amount, which is included in the member’s monthly contribution. The credit facility is immediately available at enrolment.
Scheme tariff is the tariff for service as approved by Board of Trustees.
SAHPRA is tasked with regulating (monitoring, evaluating, investigating, inspecting and registering) all health products. This includes clinical trials, complementary medicines, medical devices and in vitro diagnostics (IVDs). Furthermore, SAHPRA has the added responsibility of overseeing radiation control in South Africa. SAHPRA’s mandate is outlined in the Medicines and Related Substances Act (Act 101 of 1965 as amended), as well as the Hazardous Substances Act (Act 15 of 1973).
Sub-acute care is provided on an inpatient basis to those individuals needing services that are more intensive than those typically received in skilled nursing facilities, but less intensive than admission in acute hospital care facilities (previously Step-Down facilities). Sub-acute units tend to be housed in skilled nursing facilities or in skilled nursing units.
Service includes occupational therapy, speech therapy, dietitians, chiropody, masseurs, biokinetics etc.
Applicable medicine dispensed on prescription to take out of the hospital on the day of discharge and related to the reason for admission.
It is a description code, indicating the service rendered for a treatment being received and is, therefore, compulsory on all claims or treatment applications. A tariff code is used to give a description of services rendered by a FP in their rooms or in hospital.
Tempo is our health and wellness programme that assists members in leading a healthier lifestyle and living their best lives. It is a package of benefits and offerings, which gives members access to expert healthcare professionals. Their advice and assistance will help members understand their health risks and improve their quality of life. The Tempo wellness programme is focused on supporting you on your path to improving your health and realising the rewards that come with it.
For every CDL and PMB chronic condition, where medicine is approved, there is a basic treatment plan that is provided. The treatment plan differs from condition to condition and can include consultations, pathology and radiology. These services are paid from Scheme benefits and not from the savings account. For each approved service, there is a maximum allowed per year.
In-hospital benefits: Accommodation, take-home medication, treatment in mental health and chemical and substance abuse clinics, consultations and procedures, surgical procedures and anaesthetic, organ transplants, supplementary services, confinements etc.
Out-of-hospital benefits: FPs and specialists, diabetes primary care, basic and specialised dentistry, apparatus like hearing aids, supplementary services, wound care, optometry, basic and specialised radiology, rehabilitation after trauma, HIV/AIDS, oncology, medicine (CDL and non-CDL, OTC, biologicals.
Preventative benefits: Flu, pneumonia, HPV, HIB vaccines, paediatric immunisations, female contraceptives, Back and neck rehabilitation programmes, preventative dentistry, mammogram, pap smear, PSA screenings.
Specialised wound care therapy, including dressings and negative pressure wound therapy (NPWT) treatment and related nursing services are included in Bestmed’s provider network. Practice number is required to claim for the service provided.
