Who is BESTmed?
BESTmed is an open, registered medical scheme, administered by Sanlam Healthcare
Management (SHM). SHM is a wholly-owned subsidiary of Sanlam Life Insurance Limited,
one of South Africa’s leading financial services groups, with an enviable track record of
providing products and services that embody their values of trust, honesty, integrity and
caring.
BESTmed has been providing superior healthcare cover to thousands of South Africans
for the past 46 years and is a non-profit medical scheme. Like Sanlam, BESTmed
continually strives to offer the best, with value-for-money products supported by
BESTmed Medical Scheme
An overview of benefits for 2011
BESTmed quick facts:
•
BESTmed has a reserve ratio of 33% (above the legal
requirement of 25%). This means that it is a strong scheme and its
risk management is expertly and responsibly managed.
•
BESTmed is among the top 10 open medical schemes,
with a principal membership base of more than 65 000 members.
•
BESTmed offers ten uniquely structured options, which
are Rand-for-Rand the best value compared to many large, open
medical schemes.
•
Sanlam’s incomparable industry expertise and
managed healthcare is superior to many open medical
schemes, giving you peace of mind that BESTmed is in the best
hands.
•
BESTmed manages its option increases prudently in
order to prevent year-on-year excessive increases.
How does BESTmed work?
BESTmed’s core benefits can be broadly categorised as follows:
In-hospital
benefits Out-of-hospital benefits Medicine Preventative care Health Management Programmes This covers procedures and surgery done in hospital. These expenses are usually high, but infrequent. In-hospital expenses are paid by BESTmed up to the Scheme tariff. There are some limits for certain procedures, which are detailed in your option brochure. This includes consultations, procedures and medical expenses that take place out of hospital, e.g. GP and specialist consultations and procedures performed in a doctor’s room. Depending on the option you choose, these expenses will be paid from: • major medical benefit, or • your medical savings account, or • your bonus account, or • your day-to-day limit, or
• you will be liable for payment yourself. Please see your option brochure for more details. Prescribed medicine listed in the formulary is paid by BESTmed. Chronic medicine for the 26 Chronic Disease List (CDL) conditions will be paid in full by BESTmed provided you obtain pre-authorisation and register for the Chronic Medicine Benefit. Chronic medicine listed in the formulary for non-CDL conditions will be paid by BESTmed, but you may have a co-payment. See your option brochure for details.
This covers immunisations and examinations to prevent you from getting sick. Please see your option brochure for more details.
These programmes are aimed at managing your wellbeing and treatment if, for example, you:
• have cancer,
• are HIV positive or have AIDS,
• have a chronic condition,
• are pregnant, etc. You must register for the relevant programme/s in order to receive the benefits.
This category of benefits also includes the management of your care in hospital. Please go to www.bestmed. co.za and click on ‘Managed care’ for comprehensive information about these programmes.
Please refer to the inside of this brochure for a comparison of the ten options available
in 2011.
2011 Healthcare offering
Category 2 offers comprehensive hospital
benefits, but with
more savings options to cover extensive
out-of-hospital expenses. The options in
this category are BonusPlus, Best Gold,
Millennium Comprehensive, Topcare and
Best Platinum.
Category 3 offers a comprehensive
hospital benefit with out-of-hospital
benefits provided by designated
network providers only. The options in
this category are Best Gold Select and
BluePrint.
Once you have selected the category
that meets your broad healthcare needs,
you can then choose an option that
provides the specific benefits you are
looking for.
The table below gives you an overview
of the benefits offered by each option.
You can visit www.bestmed.co.za for
more comprehensive information on each
option before making your selection.
You will receive a brochure with detailed
information about the benefits offered
by the option you select.
We all have different needs when it comes
to healthcare. You may seldom visit a
GP, but when you have to go to hospital
unexpectedly, you want peace of mind
that you have cover to pay for in-hospital
treatment. That’s why BESTmed Medical
Scheme offers you a range of choices
to suit your personal circumstances.
BESTmed’s benefits and services are, on a
Rand-for-Rand basis, the best value when
compared to many large, open medical
schemes.
BESTmed’s range of options for 2011 has
been designed by members for members
to give you flexibility and choice over the
level of medical benefits you choose to
meet your healthcare needs.
What you select will depend on what
you’re looking for.
You may be young and single and need
the peace of mind that a comprehensive
hospital plan brings, or you may need
comprehensive medical cover for the
whole family. Our range of ten options
has been carefully structured and can be
classified into three broad categories – to
give you the choice you are looking for –
at a price you can afford.
Category 1 offers comprehensive hospital
benefits with limited savings to pay for
out-of-hospital expenses. The options in
this category are Beat 1♥, Beat 2♥♥ and
Beat 3♥♥♥.
Beat 1♥ Beat 2♥♥ Beat 3♥♥♥ In-hospital
benefits
• Private hospital costs are paid at 100% of the BESTmed tariff (pre-authorisation must be obtained).Some sub-limits apply for certain procedures.
• Unlimited cover is provided for Prescribed Minimum Benefits in State facilities.
Out-of-hospital benefits
You pay for all out-of-hospital, day-to-day medical expenses, e.g. GP and specialist visits, etc.
You pay for all out-of-hospital expenses from your medical savings account. When your medical savings account is exhausted, you pay for them yourself.
You pay for out-of-hospital expenses from your medical savings account. When your medical savings account is exhausted, you pay for them yourself. Basic dentistry according to BESTmed protocol, limited optometry services, MRI & CT scans are paid from scheme funds.
Savings
account None. Savings equal to 15% of your total annual contribution are available at the start of the benefit year to pay for medical expenses, e.g. GP visits, medicine, etc.
Savings equal to 15% of your total annual contribution are available at the start of the benefit year to pay for medical expenses, e.g. GP visits, medicine, etc.
Chronic
medicine Chronic medication is provided for diseases on the Chronic Disease List (CDL).
Co-payment of 35% for non-formulary medicine.
Chronic medication is provided for diseases on the Chronic Disease List (CDL). Non-CDL medication is payable from your medical savings account. Co-payment of 35% for non-formulary medicine.
Chronic medication is provided for diseases on the Chronic Disease List (CDL) plus 5 non-CDL conditions with a 15% co-payment up to the annual limit. Co-payment of 35% for non-formulary medicine. You must be registered on the Chronic Care Programme to receive chronic medication, paid for by BESTmed.
Preventative care
(*Subject to BESTmed protocols)
Flu vaccines, Pneumonia programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documen-tation Based Care)*.
Flu vaccines, Pneumonia programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documen-tation Based Care)*, Basic/preventative dentistry.
Flu vaccines, Pneumonia programme*, Paediatric immunisations, Oral contraceptives - R1 200 per family per year, Back rehabilitation programme (provided by Documentation Based Care)*, Basic/preventative dentistry.
Co-payments R1 000 on all endoscopic investigations if performed in hospital. If performed in doctor’s rooms, no co-payment.
R1 000 on all endoscopic investigations if performed in hospital. If performed in doctor’s rooms, no co-payment.
R1 000 on all endoscopic investigations if performed in hospital. If performed in doctor’s rooms, no co-payment.
BonusPlus Best Gold Millennium
Comprehensive Topcare Platinum
In-hospital
benefits • Private hospital costs are paid at 100% of the BESTmed tariff (pre-authorisation must be obtained).Some sub-limits apply for certain procedures. • Unlimited cover is provided for Prescribed Minimum Benefits in State facilities.
Out-of-hospital benefits
Out-of-hospital expenses are paid from your medical savings account until exhausted, then overall annual limit up to sub-limits, then your bonus account.
Out-of-hospital expenses are paid from your annual overall limit up to limit or benefit sub-limits. When annual limit or a sub-limit is reached, further expenses will be for your own account.
Out-of-hospital expenses are paid from your medical savings account first until you reach the threshold. When the threshold is reached, the expenses are then paid from the above-threshold benefits up to the specified sub-limits.
Out-of-hospital expenses are paid from your annual overall limit up to limit or benefit sub-limits. When annual limit or a sub-limit is reached, further expenses are paid from your medical savings account.
Out-of-hospital expenses are paid from your annual overall limit up to limit or benefit sub-limits. When annual limit or a sub-limit is reached, further expenses are paid by you.
Savings
account Savings equal to 22% of your total
monthly contribution are available each month. Unused monthly savings are transferred to the bonus account after four months.
None. Savings equal to 17% of your total annual contribution are available at the start of the benefit year to pay for medical expenses. .
Savings equal to 18% of your total annual contribution are available at the start of the benefit year to pay for medical expenses once you’ve reached your overall limit or a particular sub-limit.
None.
Chronic
medicine Chronic medication is provided for diseases
on the Chronic Disease List (CDL) plus 15 non-CDL conditions with a 15% co-payment up to the annual limit. Co-payment of 35% for non-formulary medicine.
Chronic medication is provided for diseases on the Chronic Disease List (CDL) plus 31 non-CDL conditions with a 15% co-payment up to the annual limit. Co-payment of 25% for non-formulary medicine.
Chronic medication is provided for diseases on the Chronic Disease List (CDL) plus 31 non-CDL conditions with a 15% co-payment up to the annual limit. Co-payment of 25% for non-formulary medicine.
Chronic medication is provided for diseases on the Chronic Disease List (CDL) plus 31 non-CDL conditions with a 15% co-payment up to the annual limit. Co-payment of 25% for non-formulary medicine.
Chronic medication is provided for diseases on the Chronic Disease List (CDL) plus 45 non-CDL conditions with a 15% co-payment up to the annual limit. Co-payment of 20% for non-formulary medicine. You must be registered on the Chronic Care Programme to receive chronic medication, paid for by BESTmed.
Preventative care
(*Subject to BESTmed protocols)
Flu vaccines, Pneu-monia programme*, Paediatric immunisa-tions, Oral contracep-tives - R1 200 per family per year, Back rehabilitation pro-gramme (provided
Flu vaccines, Pneu-monia programme*, Paediatric immunisa-tions, Oral contra-ceptives - R1 200 per family per year, Back rehabilitation programme
(pro-Flu vaccines, Pneu-monia programme*, Paediatric immunisa-tions, Oral contra-ceptives - R1 200 per family per year, Back rehabilitation programme
(pro-Flu vaccines, Pneu-monia programme*, Paediatric immunisa-tions, Oral contra-ceptives - R1 200 per family per year, Back rehabilitation programme
(pro-Flu vaccines, Pneu-monia programme*, Paediatric immunisa-tions, Oral contra-ceptives - R1 200 per family per year, Back rehabilitation programme
(pro-Category 2 Benefits
Best Gold Select BluePrint In-hospital
benefits
• Private hospital costs are paid at 100% of the BESTmed tariff (pre-authorisation must be obtained).Some sub-limits apply for certain procedures.
• Unlimited cover is provided for Prescribed Minimum Benefits in State facilities.
Out-of-hospital benefits
Out-of-hospital services are provided by the ONECARE network and paid from your annual overall limit up to limit or benefit sub-limits. When annual limit or a sub-limit is reached, further expenses are paid by you.
Primary care services are to be obtained from the ONECARE network provider.
Out-of-hospital services are provided by the Prime Cure network.
Savings
account None. None.
Chronic
medicine Chronic medication is provided for ONECARE formulary conditions plus 45 non-CDL conditions up to the annual limit.
Co-payment of 25% for non-formulary medicine.
Chronic medication is provided for Prime Cure formulary CDL and non-CDL conditions.
You must be registered on the Chronic Care Programme to receive chronic medication, paid for by BESTmed.
Preventative care
(*Subject to BESTmed protocols)
Flu vaccines, Pneumonia programme*, Paediatric immunisation, Back rehabilitation programme (provided by Documen-tation Based Care)*.
Flu vaccines, Pneumonia programme*.
Co-payments
None. R2 500 on all laparoscopic procedures. R3 000 on hip and knee replacements. R2 500 on prostate procedures.
R2 500 on procedures for prolapse/incontinence.
Category 3 Benefits
Contributions for 2011
OPTION P A C P+A P+A+C P+A+2C P+A+3C
Beat 1♥ R738 R574 R311 R1 312 R1 623 R1 934 R2 245 Beat 2♥♥ R868 R675 R366 R1 543 R1 909 R2 275 R2 641 Beat 3♥♥♥ R1 353 R961 R522 R2 314 R2 836 R3 358 R3 880 BonusPlus R1 827 R1 283 R460 R3 110 R3 570 R4 030 R4 490 Best Gold R2 444 R2 395 R538 R4 839 R5 377 R5 915 R6 453 Millennium Comprehensive R2 470 R2 346 R864 R4 816 R5 680 R6 544 R7 408 Topcare < R86 000 R2 396 R1 918 R444 R4 314 R4 758 R5 202 R5 646 Topcare >R86 000 R2 878 R2 300 R482 R5 178 R5 660 R6 142 R6 624 Platinum R3 299 R3 299 R773 R6 598 R7 371 R8 144 R8 917
Best Gold Select R2 605 R2 605 R620 R5 210 R5 830 R6 450 R7 070
BluePrint < R12 000 R671 R671 R400 R1 342 R1 742 R2 142 R2 542
BluePrint R12 001 - R48 000 R721 R680 R400 R1 401 R1 801 R2 201 R2 601
BluePrint R48 001 - R60 000 R911 R696 R400 R1 607 R2 007 R2 407 R2 807
BluePrint > R60 001 R1 014 R775 R430 R1 789 R2 219 R2 649 R3 079
OPTION P+C P+2C P+3C P+2A P+2A+1C P+2A+2C
Beat 1♥ R1 049 R1 360 R1 671 R1 886 R2 197 R2 508 Beat 2♥♥ R1 234 R1 600 R1 966 R2 218 R2 584 R2 950 Beat 3♥♥♥ R1 875 R2 397 R2 919 R3 275 R3 797 R4 319 BonusPlus R2 287 R2 747 R3 207 R4 393 R4 853 R5 313 Best Gold R2 982 R3 520 R4 058 R7 234 R7 772 R8 310 Millennium Comprehensive R3 334 R4 198 R5 062 R7 162 R8 026 R8 890 Topcare < R86 000 R2 840 R3 284 R3 728 R6 232 R6 676 R7 120 Topcare >R86 000 R3 360 R3 842 R4 324 R7 478 R7 960 R8 442 Platinum R4 072 R4 845 R5 618 R9 897 R10 670 R11 443
Best Gold Select R3 225 R3 845 R4 465 R7 815 R8 435 R9 055
BluePrint < R12 000 R1 071 R1 471 R1 871 R2 013 R2 413 R2 813
BluePrint R12 001 - R48 000 R1 121 R1 521 R1 921 R2 081 R2 481 R2 881
BluePrint R48 001 - R60 000 R1 311 R1 711 R2 111 R2 303 R2 703 R3 103
Choosing a suitable option
Are you on chronic medication?
This refers to prescribed medication that
people with certain chronic conditions
must use for long periods of time. As
a member of BESTmed, your chronic
medication will be covered if you
suffer from a condition that appears
on the list in terms of the Prescribed
Minimum Benefits or the Chronic
Disease List. There are also additional
chronic benefits on certain options for
conditions that are not covered under
the Prescribed Minimum Benefits. You
must be registered on the Chronic Care
Programme to receive chronic medication,
paid for by BESTmed. There is a separate
form to be completed by you and your
service provider when applying for this
benefit.
Your choice of option should offer the
right cover to meet the medical needs of
you and your family for the next year. It
may help to look back at your claims for
the past year to see where your highest
claims were, as well as to consider any
upcoming procedures or life-stage events
(e.g. starting a family) that could affect your
need for medical cover. In addition, consider
how much you can afford to pay for your
medical scheme cover. You can also consider
the questions below to help you make your
decision.
What day-to-day benefits do you
need?
These are usually the smaller medical
expenses that occur more often, such as
visits to your doctor or dentist. BESTmed
offers a range of day-to-day cover options
to suit you and your family’s daily medical
needs.
Do you want a medical savings
account?
A medical savings account is one way of
ensuring that money is available to settle
out-of-hospital medical costs. BESTmed
offers various savings account options
across most of its benefit options.
Managing your medical costs
Exercise: Many of the health and weight
problems that people suffer from today
are due to lack of physical exercise. Try
these tips to achieve a more active
lifestyle without going to the gym!
•
Park further away from the shopping
centre and do some extra walking.
•
Take the stairs and not the lift.
•
Dance.
•
Walk round the block or in the park –
walk the dog!
Healthy mind: When it comes to changing
your lifestyle and your behaviour the
right attitude is critical to make you stick
to the plans you put into action. Start by
adopting a positive attitude to everything
you do and remember to take time out
now and then to enjoy something that
you really love. Only you can choose to live
a healthier life.
To a large extent, the financial health
of a medical scheme is determined by
the health of its members. While we
understand that accidents and dread
diseases cannot always be predicted and,
in some cases prevented, there are things
that you can do to keep yourself healthy
and away from the doctor’s consulting
rooms. Maintaining a healthier lifestyle
will help to preserve your medical benefits
for longer so you don’t run out of benefits
during the year.
The lives we live have a lot to do with how
we feel about life and, more importantly,
about the health of our bodies. Three vital
aspects of a healthy lifestyle are:
Diet: You’ve heard or read it all before. But
here are some of the good old healthy
eating tips to keep in mind every day:
•
Drink at least eight glasses of water a
day.
•
Eat three balanced and healthy meals a
day – don’t forget lots of fresh fruit and
vegetables!
•
Watch those unhealthy snacks.
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. This benefit overview is pending the Registrar’s approval.
