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Pace 1

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Type of Medical Aid Plan: 
Hybrid
Medical Aid Year: 
2020
Day to day Benefits: 

Overall day-to-day limit of M = R11 382; M1+ = R20 763

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% of Bestmed Tariff (BT)
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: 
PMBs only at DSPs
Organ Transplants: 
100% of BT. PMBs only
Oncology / Cancer: 
PMBs only at DSPs
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 R85 948 per family.
Internal: Sub-limits per beneficiary: Functional limited to R15 437; Vascular R31 325; Pacemaker (dual chamber) R53 492; Endovascular and catheter-based procedures - No benefit; Spinal R31 325; Artificial disc - No benefit; Drug-eluting stents PMBs and DSPs only; Mesh R11 761; Gynaecology/Urology R8 482; Lens implants R6 447 per lens, per eye. PMB prosthesis limits; hip replacement and other major joints R31 891; knee replacement R42 409; minor joints R13 175.
External: limited to R21 827 per family

Medical and Surgical Appliances: 
In hospital; 100% of BT. Out of hospital; overall day-to-day limit. Savings first, limited to R10 970 per family. Hearing aids subject to pre-authorisation
Maternity Confinements: 
100% of BT
In Hospital Dentistry: 
Limited to R7 690 per family. Maxillofacial surgery at 100% of BT, limited to R12 440 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 R30 760 per beneficiary
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 limit. Savings first, limited to M = R2 138, M1+ = R4 297 for GP and specialist consultations

Specialist consultations: 

Subject to overall day-to-day limit. Savings first, limited to M = R2 138, M1+ = R4 297 for GP and specialist consultations

Acute medicine: 

Subject to overall day-to-day limit. Savings first, limited to M = R2 240, M1+ = R4 637

Over-the-counter (OTC) Medicine: 

Member choice: 1. R650 limit 2. Access to full available savings after R650 limit = self payment gap accumulation

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 510
Basic dentistry: 
Preventative benefit or savings account. Limit once savings exceeded of M = R3 934, M1+ = R7 985
Specialised Dentistry: 
Savings account then limit of M = R3 934, M1+ = R7 985
Orthodontics: 

Subject to overall day-to-day limit. Limited to M = R3 934, M1+ = R7 985. Subject to pre-authorisation.

MRI and CT Scans (Out of Hospital): 
100% of BT. Limited to R13 911 per family
Radiology and Pathology: 
Subject to overall day-to-day limit. Savings first, limited to M = R3 110, M1+ = R6 220
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. Antenatal iron and folic acid supplements x 9 fills
Physiotherapy and Occupational Therapy day to day: 
Subject to overall day-to-day limit. Savings first, limited to M = R4 195, M1+ = R8 708
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: 
7 conditions. 90% of BT and limited to M = R6 333; M1+ = R12 666
Preventative Care Benefits
Preventative Benefits: 

Flu and pneumonia vaccines; haemophilus influenza type B (HIB) vaccine; paediatric immunisation; female contraceptives R2 205 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: 
3930.00
Total Contribution Adult: 
2760.00
Total Contribution Child*: 
992.00
Pace 1
Annual Medical Savings Account
Annual Medical Savings Main Member: 
8964.00
Annual Medical Savings Adult: 
6288.00
Annual Medical Savings Child*: 
2256.00
Monthly Medical Savings
Savings Child*: 
188.00
Savings Adult: 
524.00
Savings Main Member: 
747.00
Risk Contributions
Risk Contribution Main Member: 
3183.00
Risk Contribution Adult: 
2236.00
Risk Contribution Child: 
804.00
Medical Aid Plan Name Term: 
Pace 1