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Pace 4

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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 = R34 153; M1+ = R55 075

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 overall day-to-day limit
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
Organ Transplants: 
100% of BT
Oncology / Cancer: 
Oncology programme at 100% of BT
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: 
Subject to DSPs and prosthesis limits
Prosthesis: 

100% of BT. Subject to preferred providers and prosthesis limit of R128 018 per family.
Internal: Sub-limits per beneficiary: Functional limited to R18 773; Vascular R47 498; Pacemaker (dual chamber) R59 655; Spinal including artificial disc R64 014; Drug-eluting stents R21 318; Mesh R18 733; Gynaecology/Urology R15 494; Lens implants R17 156 per lens, per eye; Hip replacement and other major joints R57 280; knee replacement R66 328; minor joints R21 318.
External: limited to R29 517 per family

Medical and Surgical Appliances: 
In hospital; 100% of BT. Out of hospital; overall day-to-day limit. Limited to R9 952 per family. Wheelchairs limited to R13 458 pf. Hearing aids limited to R34 379, insulin pump limited to R40 000, both subject to pre-authorisation
Maternity Confinements: 
100% of BT
In Hospital Dentistry: 
Limited to R19 225 per family. Maxillofacial surgery at 100% of BT
Take home Medicine: 
100% of BT. Limited to 7 days supply
Rehabilitation, Hospice and Step-down facilities: 
100% of BT 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. Limited to M = R5 372, M1+ = R8 708 for GP and specialist consultations

Specialist consultations: 

Subject to overall day-to-day limit. Limited to M = R5 372, M1+ = R8 708 for GP and specialist consultations

Acute medicine: 

Subject to overall day-to-day limit and 10% co-payment. Limited to M = R8 482, M1+ = R13 175

Over-the-counter (OTC) Medicine: 

Savings account

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: 
Basic and specialised dentistry are subject to overall day-to-day limit. Limited to M = R11 861, M1+ = R20 020
Specialised Dentistry: 
Basic and specialised dentistry are subject to overall day-to-day limit. Limited to M = R11 861, M1+ = R20 020
Orthodontics: 

Basic and specialised dentistry are subject to overall day-to-day limit. Limited to M = R11 861, M1+ = R20 020. Subject to pre-authorisation

MRI and CT Scans (Out of Hospital): 
100% of BT. Maximum of 3 scans per beneficiary. PET scan; 1 per beneficiary
Radiology and Pathology: 
Subject to overall day-to-day limit. Limited to M = R5 372, M1+ = R10 574
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. Limited to M = R5 372, M1+ = R10 574
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: 
28 conditions. 90% of BT and limited to M = R18 942; M1+ = R38 055. Biological and other high-cost medicine limited to R468 645
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, bone densitometry 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: 
7983.00
Total Contribution Adult: 
7983.00
Total Contribution Child*: 
1870.00
Pace 4
Annual Medical Savings Account
Annual Medical Savings Main Member: 
2880.00
Annual Medical Savings Adult: 
2880.00
Annual Medical Savings Child*: 
684.00
Monthly Medical Savings
Savings Child*: 
57.00
Savings Adult: 
240.00
Savings Main Member: 
240.00
Risk Contributions
Risk Contribution Main Member: 
7743.00
Risk Contribution Adult: 
7743.00
Risk Contribution Child: 
1813.00
Medical Aid Plan Name Term: 
Pace 4