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Beat 4 2021

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Type of Medical Aid Plan: 
Hybrid
Medical Aid Year: 
2021
Day to day Benefits: 

Subject to overall day-to-day limit of M = R12 824 or M1+ = R25 649. Claims are paid from savings account first, which is 14% of the monthly contribution 

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% of Bestmed Tariff (BT). Day procedures are funded at 100% of BT in a day-hospital facility
Hospitals: 

Any

Casualty / Emergency Visits: 
Subject to savings
Specialists: 
100% of BT
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of BT
Radiology and pathology: 
100% of BT
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100% of BT
MRI and CT scans: 
100% of BT
ICU and High Care: 
100% of BT
Dialysis: 
100% of BT. Subject to pre-authorisation and DSP's
Organ Transplants: 
100% of BT. PMBs only
Oncology / Cancer: 
100% of BT. Subject to pre-authorisation, the ICON network and ICON standard protocols
Neck and Back Operations: 
Subject to the outcome of referral, assessment and rehabilitation treatment at a Bestmed Document Based Care (DBC) back and neck treatment programme
Joint Replacements: 
PMBs only at DSPs and subject to prosthesis limits
Prosthesis: 

100% of BT. Subject to preferred providers and prosthesis limit of R97 260 per family. Internal: Sub-limits per beneficiary: Functional limited to R16 981; Vascular R33 605; Pacemaker (dual chamber) R56 285 Endovascular and catheter-based procedures - No benefit; Spinal R33 605; Artificial disc - No benefit; Drug-eluting stents- R18 881; Mesh R12 469; Gynaecology/Urology R9 144; Lens implants R7 125 per lens, per eye. PMB prosthesis limits; hip replacement and other major joints R34 555; knee replacement R45 907; minor joints R14 106. External: Limited to R23 393 per family

Medical and Surgical Appliances: 
In hospital; 100% of BT. Out of hospital; overall day-to-day limit. Limited to R11 519 per family. Hearing aids subject to pre-authorisation
Maternity Confinements: 
100% of BT
In Hospital Dentistry: 
Limited to R10 094 per family. Maxillofacial surgery at 100% of BT, limited to R13 181 per family
Take home Medicine: 
100% of BT. Limited to 7 days supply
Rehabilitation, Hospice and Step-down facilities: 
Vested savings for rehabilitation after trauma. Chemical and substance abuse are subject to network facilities and limited to 21 days or R32 299 per beneficiary. Palliative and home-based care; R10 000 per month for 3 months. Subject to pre-auth and DSP's
Treatment for Mental Health: 
100% of BT. Limited to 21 days per beneficiary
HIV / AIDS: 
100% of BT. Subject to pre-authorisation and DSPs
Ambulance Service: 
ER 24 for emergencies
International Travel Benefit: 
Up to R10 million and a maximum of 90 days. Services rendered by Bryte Insurance and managed by ER24
Day-to-day benefits
GP consultations: 

Subject to overall day-to-day benefit. Savings first. Limited to M = R3 265; M1+ = R5 818

Specialist consultations: 

Subject to overall day-to-day benefit. Savings first. Limited to M = R3 265; M1+ = R5 818

Acute medicine: 

Subject to overall day-to-day benefit. Savings first. Limited to M = R2 885; M1+ = R5 830

Over-the-counter (OTC) Medicine: 

Choice between R683 limit or access to available savings after the R683 limit is reached

Optometry benefits: 
Subject to services rendered by a PPN provider per 24 month cycle. Consultation, frame and 100% of cost for standard lenses or contact lenses = R1 565
Basic dentistry: 
Basic and specialised dentistry are subject to overall day-to-day limit. Savings first, limited to M = R5 650, M1+ = R11 349
Specialised Dentistry: 
Basic and specialised dentistry are subject to overall day-to-day limit. Savings first, limited to M = R5 650, M1+ = R11 349
Orthodontics: 

Subject to overall day-to-day benefit. Savings first. Limited to M = R5 650; M1+ = R11 349 and pre-authorisation

MRI and CT Scans (Out of Hospital): 
100% of BT. Limited to R16 981 per family, excluding PET scans
Radiology and Pathology: 
Subject to overall day-to-day limit. Savings first, limited to M = R3 265, M1+ = R6 650
Pregnancy benefits: 
Subject to registration on the Maternity Care programme after 12 weeks; 9 antenatal and 1 post-natal consult at a GP or gynaecologist or midwife and 2x 2D scans. Maternity supplements x 9 to a maximum of R100 per month
Physiotherapy and Occupational Therapy day to day: 
Subject to overall day-to-day limit. Savings first, limited to M = R4 987, M1+ = R10 129
Chronic Conditions
Provider: 
Bestmed pharmacy network
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to approval

Additional Chronic Conditions: 
9 conditions. 90% of BT and limited to M = R7 564; M1+ = R15 129
Preventative Care Benefits
Preventative Benefits: 

Flu, pneumonia and travel vaccines; paediatric immunisation; female contraceptives R2 315 pbpa; back and neck preventative programme; preventative dentistry; age and frequency specific tests for pap smear; HPV vaccines; mammogram and PSA screening. Tempo programme has Individual Health Risk Assessments for adults aged 18 and older and age specific assessments for child dependants aged 0 - 17 years; family nutrition assessment and fitness and nutritional interventions for beneficiaries aged 18 and older

Total Contributions
Total Contribution Main Member: 
4872.00
Total Contribution Adult: 
4024.00
Total Contribution Child*: 
1204.00
Beat 4
Annual Medical Savings Account
Annual Medical Savings Main Member: 
8184.00
Annual Medical Savings Adult: 
6756.00
Annual Medical Savings Child*: 
2028.00
Monthly Medical Savings
Savings Child*: 
169.00
Savings Adult: 
563.00
Savings Main Member: 
682.00
Risk Contributions
Risk Contribution Main Member: 
4190.00
Risk Contribution Adult: 
3461.00
Risk Contribution Child: 
1035.00
Medical Aid Plan Name Term: 
Beat 4