10 20 - VUT

The trusted choice... always

2010

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BESTmed product offeringThe BESTmed product offering is extensive and meets the unique and individual healthcare needs of our members. We have taken great care and put thought into designing our products by analysing the lifestyles, health profiles and socio-economic circumstances of our market. Our product offerings range from comprehensive cover for hospital and out-of-hospital services to products offering limited out-of-hospital benefits, but comprehensive in-hospital benefits. No matter your age, income, health profile or gender, we have the option that will BEST suit you!

Product rangeThe product offerings differ from each other on the basis of the following criteria:

• Cover for hospital services• Cover for out-of-hospital services• Cover for chronic medicine• Freedom of choice with regard to service provider networks• Access to disease management programmes and preventative care• Contributions

Contributions

Risk contribution

Savings contribution

Total monthly

contribution

Annual savings account

Principal member

R1 278 R360 R1 638 R4 320

Spouse/Adult dependant

R898 R253 R1 151 R3 036

Child (Max. 4) * R322 R91 R413 R1 092

* You only pay for a maximum of four children. All other children are allowed as beneficiaries on the Scheme free of charge.

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This option caters for large families and has a holistic approach in terms of benefits. Granting of day-to-day benefits is subject to an overall annual limit of R6 500 (single member) or R13 000 (family) and service specific sub-limits as indicated in this benefit summary.

Who should be on Bonus Plus?Families and single members who require more day-to-day cover due to specific requirements such as acute medication and members who prefer to go to their own service provider. It also includes:• Day-to-day benefits subject to overall annual limits• BESTbaby programme

HOSPITAL TREATMENT No overall annual limit Pre-authorisation required

SCHEME BENEFIT APPLICABLE TARIFFS

BENEFIT AMOUNT

Accommodation (hospital stay) 100% of contracted fee

Unlimited

Theatre fees 100% of contracted fee

Unlimited

Take home medicine 100% of cost Limited to seven days’ supply

Treatment in mental health clinics 100% of scheme tariff

21 days per beneficiary

Treatment of chemical & substance dependence/abuse

100% of scheme tariff

21 days or R13 000 per beneficiary

Consultations & procedures 100% of scheme tariff

Unlimited

Surgical procedures & anaesthetics for surgical procedures & operations, excluding dental operations

• Organ transplants



Unlimited

Subject to pre-authorisation & protocols.

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SCHEME BENEFIT APPLICABLE TARIFFS

BENEFIT AMOUNT

Maxilla-facial & oral surgery strictly related to certain conditions


R6 720 per family. Subject to pre-authorisation.

Pathology & radiology (including MRI & CT scans)


Unlimited

Physiotherapy & biokinetics 100% of scheme tariff

Limited to M = R4 000M+ = R6 000

Confinements 100% of scheme tariff

Unlimited

Oncology treatment(radiation & chemotherapy)


Subject to pre-authorisation & registration on oncology programme.

Prosthesis (per family)Internal: • Vascular / Spinal• Hip replacement• Mesh• Knee replacement• Gynaecology / Urology• Lens implants

Artificial disk / Drug eluting stents (DES) - no benefit

External: • Artificial limb

100% of cost Limited to R35 000

• R15 000 per type• R18 000 • R6 000• R24 000• R4 000 per type• R3 000

Limited to R10 000 One per 60 months

Alternatives to hospitalisation 100% of approved fees

R15 000 per family

Emergency evacuation 100% of cost Unlimited Rendered & pre-authorised by ER24.

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OUT-OF-HOSPITAL TREATMENT

• Out-of-hospital medical expenses are either paid from scheme benefits (as indicated) or from the monthly contribution towards the savings account and thereafter from scheme benefits called the day-to-day benefits.

• The overall annual limit on day-to-day benefits is R13 000 for a family and R6 500 for a single member without dependants. Within the annual amount available for day-to-day benefits, certain service specific limits are also applicable. These limits are indicated in the table below.

• Unutilised amounts contributed towards the savings account per month are carried over to the bonus account after four months. These funds will then be used to pay for out-of-hospital benefits should the annual limits for day-to-day benefits have been reached.

• Services paid from day-to-day benefits are paid in accordance to the scheme tariff structure and are limited to those amounts as indicated under each type of service. Services paid from the savings account are paid at 100% of cost.

• Scheme benefits (not subject to overall limit on day-to-day benefits).

SCHEME BENEFITSBENEFIT AMOUNT AVAILABLE

SINGLE MEMBER FAMILIESMedicine (refer to page 9)Non-CDL chronic



CDL chronic Unlimited. Subject to formulary & pre-authorisation.MRI & CT scans Limited to R5 000 per family.

DAY-TO-DAY BENEFITS (subject to overall limit of R6 500 (single member) and R13 000 (families))

DAY-TO-DAY BENEFITSBENEFIT AMOUNT AVAILABLE

SINGLE MEMBER FAMILIESConsultations, visits & medication not approved as CDL or non-CDL medicine (over-the-counter medicine – limited to R350 per family per year)

R2 200 R4 400

Oral & dental services R2 200 R5 500

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DAY-TO-DAY BENEFITSBENEFIT AMOUNT AVAILABLE

SINGLE MEMBER FAMILIESSupplementary services R2 200 R4 400Optical services, per beneficiary per 24 months

R1 100 R2 200

Refractive surgery, protocol applies R2 750 R2 750Orthopaedic surgical & medical appliances

R5 500 R5 500

Basic Radiology & Pathology R1 650 R3 300

PREVENTATIVE CAREThis option provides cover for preventative treatment that will be paid in accordance to scheme tariffs as scheme benefits:

Immunisation programmesImmunisation Age FrequencyInfluenza vaccination All ages AnnuallyPneumococcal vaccination, subject to scheme protocol

All ages Once off

Physical examinations and testsExamination Age Minimum frequencyFull examination on request by the Scheme when joining

All ages Once off

HIV test All ages One test per year

ADDITIONAL INFORMATION

Savings accountThis option makes provision for a savings account that amounts to 22% of the total monthly contribution amount. Members do not have access to the annual amount in advance in the beginning of the year, but only to the monthly contribution towards the savings account. All services received within a specific month will first be paid from the monthly savings account contribution and when this amount is depleted, it will be paid from the day-to-day benefit amounts. Should a member claim less than the savings account contribution during a month, these unutilised funds will be carried over to the bonus account after four months. As soon as the annual overall limit on day-to-day benefits is reached or when the service specific

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limits are reached, further claims may be paid from the bonus account (unused savings contributions). Unutilised funds in the bonus account at the end of the year will be carried over to the next year.

Submitting a claimPlease submit the original claim directly to BESTmed if the service provider does not submit claims to the Scheme. Ensure that your personal details, membership number and claiming details are correct before submitting the original account. All claims must be submitted within four months from the date of service.

Settlement of a claimClaims are processed within 48 hours after receipt. BESTmed currently has two claims payment runs per month – one in the middle of the month and one at the end of the month.

If we have your correct banking details and you pay an account in full, we will reimburse you within seven working days after receipt. Please remember to attach the proof of payment.

If we have your correct e-mail detail you will receive a mini-statement notifying you the day after a claim was processed. You are notified on the status of the claim and you may reply to the e-mail with any enquiry regarding that claim/s.

A complete claims statement (remittance advice) is sent to members after each claims payment run. Please ensure that you agree with the details as reflected on the statement. These statements are sent to members in paper format or in electronic version.

DISEASE MANAGEMENT PROGRAMMES

Oncology programme• Access to additional benefits and services that form part of the treatment

protocol.• These services include the following treatment: chemotherapy, radiation

therapy, certain pathology*, certain radiology* and certain consultations*.• Provided that:

▫ the services shall be pre-authorised by BESTmed▫ preferred providers may be appointed by BESTmed▫ the services fall within BESTmed’s protocol criteria

* Details of these services will be provided to members with their registration on the oncology programme.

Tel: 012 339 9446/9400

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HIV/AIDS treatment • Access to additional benefits and services to be received in private facilities

as part of the services offered in the HIV/AIDS management programme as provided and managed by Optipharm.

• Patients need to register on the HIV/AIDS programme in order to qualify for these additional benefits and services.

• Post Exposure Prophylaxis (PEP) • Prevention of mother-to-child transmission• BESTbaby programme • Additional benefits and services to be included in the maternity programme

that forms part of the BESTbaby programme.

Chronic diseases • Chronic conditions as well as CDL conditions• Interactive management programme, involving providers and members• Approved conditions will be funded from high risk benefit Health days • Screening for potential serious diseases• Vaccines• Arranged at participating employer organisations• Subject to certain criteria and requirements as determined by the Scheme

Hospital benefit management • Hospital pre-authorisation • Case management• Account auditing

Tel: 011 251 9400

Tel: 086 111 1936

Tel: 086 000 2378

Tel: 012 339 9440

Authorisations: 0800 220 106

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MEDICINE RE-IMBURSEMENT

The following principles apply for reimbursement on all medicine:• Where medicines have generic alternatives registered with the Medicines

Control Council of South Africa, the Scheme will reimburse those medicines up to the generic reference price (MRP) for that active ingredient.

• Benefit amount of medicine will be calculated at the Single Exit Price (SEP) plus dispensing fee as determined by the Scheme plus VAT (if applicable).

• Designated Service Providers (DSP) may apply.

Chronic medicine for Chronic Disease List (CDL) conditionsBenefits are subject to the following:• Pre-authorisation• Formularies• Unlimited benefit• Medicines on the formulary will be reimbursed without a co-payment. A 35%

co-payment for the member will apply for non-formulary medicine.

CDL conditions• Addison’s disease • Epilepsy

• Asthma • Glaucoma

• Bipolar mood disorder • Haemophilia

• Bronchiectasis • Hyperlipidaemia

• Cardiac failure • Hypertension

• Cardiomyopathy • Hypothyroidism

• Chronic obstructive pulmonary disease

• Multiple sclerosis

• Chronic renal disease • Parkinson’s disease

• Coronary artery disease • Rheumatoid arthritis

• Crohn’s disease • Schizophrenia

• Diabetes insipidus • Systemic lupus erythematosis

• Diabetes mellitus types 1 & 2 • Ulcerative colitis

• Dysrhythmia

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Chronic medicine for non-CDL chronic conditionsBenefits are subject to the following:• Pre-authorisation• Formularies• Medicines on the formulary will be reimbursed with a co-payment of 15% . A

35% co-payment for the member will apply for non-formulary medicine.• Limited to R5 000 for a member and R10 000 for a family.

Non-CDL conditions• Ankylosing spondylitis • Motor neuron disease

• Chronic allergic rhinitis • Muscular dystrophy and other inherited myopathies

• Collagen diseases • Myasthenia gravis

• Cushing’s disease • Obsessive compulsive disorder

• Dermatomyositis • Paget’s disease

• Fibrosing alveolitis • Paraplegia/Quadriplegia (medicines to manage)

• Gout • Polyarteritis nodosa

• Graves’ disease • Pulmonary embolism

• Hyperthyroidism • Pulmonary interstitial fibrosis

• Hypoparathyroidism • Scleroderma

• Hypophyseal adenoma • Sjögren’s disease

• Hypopituitarism • Stroke

• Idiopathic trombocytopenic purpura

Largefamilies

Specialists Dentistry Hospital cover

HIV / AIDS Savings account

BESTbaby programme

22%Medicine

EXCELLENT ACCESS

Post/Surface mailPO Box 2297, Arcadia, Pretoria, 0001

Physical address• 551 Belvedere Street, Arcadia, Pretoria• 4 Third Street, Marlands, Germiston

Fax: 012 339 9900Call centre: 086 000 2378 or 086 000 BESTE-mail: [email protected]

Webmail facilityFor a summary of your personal and benefit details, register on www.bestmed.co.za as per the instructions.After registration send an empty e-mail to [email protected] and receive information on benefits and recent claims.

SMS facilityTo request information on the following:A = Personal detailsB = Summary of benefits still availableC = Confirmation of three most recent claims

receivedSend A, B or C to 31416 and await requested information via SMS

Disclaimer: Whilst BESTmed has taken all reasonable care in compiling this summary, we cannot accept liability for any errors or omissions contained herein. Please note that should a dispute arise with regard to any benefit, the registered Rules of BESTmed as approved by the Registrar of Medical Schemes shall prevail.

Regional officesGauteng 080 028 7633Free State 086 010 5153Western Cape 086 010 5154Port Elizabeth 086 010 4950East London/Mthatha 086 010 4950KwaZulu-Natal 086 010 9920Mpumalanga 086 010 4950Limpopo 086 099 9633

www.bestmed.co.za

Pre-authorisation0800 22 0106 or [email protected] for ambulance emergency evacuation: 084 124

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10 20 - VUT