2011 Benefit Guide
Why Choose BESTmed? BESTmed’s Benefit Options is
One of the most important criteria you should Designed by Members for Members
consider when choosing a medical scheme is its It is a fact that private healthcare is expensive. At
reserve level. A scheme’s reserve level indicates BESTmed we understand that very well. That’s why
its ability to pay claims. BESTmed’s reserve ratio is our benefit options are designed by members for
33.2% - the legal requirement is 25%, a testament members, who understand that investing in quality
to a Scheme whose risk management is expertly and healthcare for themselves and their families is
responsibly administered. Other reasons to choose essential.
We want you to be able to select the appropriate
• We are a well established Scheme, in operation for medical cover for you and your loved ones. BESTmed
more than 46 years. therefore offers a comprehensive range of benefit
• We are amongst the top 8 open medical schemes options that are easy to understand and caters for all
with a national footprint. needs – from the young, healthy and active to those
• We have grown in membership base by 11.5% enjoying their golden years.
compared to a mere 0.3% industry average. Please speak to your intermediary to assist you in
• We pride ourselves with an incomparable industry choosing the option that best meets you and your
expertise and managed healthcare competence. family’s needs. You can also find more information on
• We have been highly rated by ASK Africa for our BESTmed’s other options on the BESTmed website at
outstanding service delivery. www.bestmed.co.za.
The secret of our success is that what you see is
what you get – there are no hidden costs or fine print.
The Best Platinum Option is for You, if: An Overview of the Best Platinum
• You require comprehensive day-to-day cover.
• You live by the rule ‘prevention is better than • Comprehensive hospital benefits
cure’ - you have access to preventative care • Chronic medicine for Chronic Disease List (CDL)
benefits which includes flu vaccines, paediatric conditions
immunisations, oral contraceptives, back
• Chronic medicine for non-CDL conditions
rehabilitation, basic and preventative dentistry, PAP
smear, mammogram, lipogram, prostate screening • Preventative care benefits
test, etc. • Wellness Management Programmes
• You realise that at any time you might be faced • International Travel Cover
with expensive, unforeseen hospital costs.
• You are in need of extensive cover for chronic
• You prefer freedom of choice when it comes to
visiting a healthcare service provider.
Principal member R3 299
Adult dependant R3 299
Child dependant* R773
* You only pay for a maximum of four children. All other children can join as beneficiaries on the Scheme free of charge.
BENEFIT SUMMARY 4
In-Hospital Scheme Benefits 4
Out-of-Hospital Benefits 6
Preventative Care Benefits 10
Wellness Management Programmes 12
24 Hour Emergency Evacuation 13
International Travel Cover 13
Prescribed Minimum Benefits (PMBs) 14
IMPORTANT ADMINISTRATIVE INFORMATION 15
ONLINE SERVICES 17
CONTACT DETAILS 18
In-Hospital Scheme Benefits
Expenses incurred in hospital will be paid at 100% of the BESTmed tariff. You must obtain an authorisation
number from BESTmed by calling 0800 22 0106. Please refer to page 15 for more details regarding
“Expenses incurred in hospital Medical event Scheme benefit
will be paid at 100% of the Accommodation (hospital stay) 100% of BESTmed tariff is paid.
BESTmed tariff. You must obtain Theatre fees 100% of BESTmed tariff is paid.
an authorisation number from Take home medicine 100% of BESTmed tariff is paid but limited to 7 days’ medicine.
BESTmed by calling Treatment in mental health clinics 100% of BESTmed tariff is paid but limited to 21 days per beneficiary.
0800 22 0106. Please refer Treatment of chemical and substance abuse 100% of BESTmed tariff is paid but limited to 21 days or
R16 000 per beneficiary.
to page 15 for more details Consultations and procedures 100% of BESTmed tariff is paid.
regarding pre-authorisation.” Surgical procedures and anaesthetics for surgical 100% of BESTmed tariff is paid.
procedures and operations
Organ transplants 100% of BESTmed tariff is paid.
Subject to pre-authorisation and protocols.
Maxilla-facial surgery strictly related to certain conditions 100% of BESTmed tariff is paid.
Prosthesis – Internal Paid at 100% of cost but limited to R70 000 per family per year.
The following sub-limits apply per beneficiary:
• Vascular R25 000
• Spinal R25 000
• Artificial disk R11 000
• Drug eluting stents R11 000
• Mesh R10 000
• Gynaecology/Urology R8 000
• Lens implants R9 000 per lens
In-Hospital Scheme Benefits (continued)
Medical event Scheme benefit
Prosthesis – External Sub-limit of R16 000 per family per prosthesis and condition
Pathology 100% of BESTmed tariff is paid.
Radiology 100% of BESTmed tariff is paid.
MRI and CT scans 100% of BESTmed tariff is paid.
Oncology 100% of BESTmed tariff is paid.
Subject to pre-authorisation and registration on the Oncology
Peritoneal dialysis and haemodialysis 100% of BESTmed tariff is paid.
Subject to pre-authorisation and protocols.
Confinements 100% of BESTmed tariff is paid.
Co-payments The following co-payments apply:
• Shoulder surgery R1 200
• Joint replacement (e.g. hip and knee
• replacements) R1 200
• Laparoscopic nissen R1 200
• Spinal surgery R1 200
• Hysterectomy R800
• Arthroscopy R400
Out-of-hospital costs will be Medical event Scheme benefit
paid by BESTmed as per the GP and Specialist consultations Limited to R3 000 for a member and R5 000 for a family.
table below from your overall Subject to the overall annual limit.
Basic and specialised dentistry Limited to R6 000 for a member and R10 000 for a family.
annual limit, which is R25 000
Subject to the overall annual limit.
for a member and R40 000 for
Medical apparatus Limited to R18 000 per family per year up to the sub-limits of:
a family. Once this overall limit or • Wheelchairs R8 000 per family per 60 months
a sub-limit for a specific benefit • Hearing aids R10 000 per beneficiary per 48 months
has been reached, further out- Supplementary services such as physiotherapy, speech Limited to R3 000 for a member and R6 000 for a family.
therapy and occupational therapy Subject to the overall annual limit.
of-hospital expenses will be for
Optical benefits Eye test, frames, lenses OR contact lenses are limited to
your own account. R3 000 for a member and R5 000 for a family.
Frames are limited to R1 000 per beneficiary per 24 months.
Subject to the overall annual limit.
Radiology and pathology Limited to R3 000 for a member and R6 000 for a family.
Subject to the overall annual limit.
Maternity Combined limit – included with GP and Specialist benefit.
Specialised radiology Subject to pre-authorisation.
MRI/CT scans: Maximum of three scans per beneficiary.
PET scan: One scan per beneficiary.
Rehabilitation services after trauma 100% of BESTmed tariff is paid.
Subject to pre-authorisation and protocols.
Benefit description Scheme benefit “The medicine listed in the
**Non-CDL chronic condition medicine 45 non-CDL conditions are covered at 85% of the BESTmed tariff. formulary for CDL chronic
Please note that CDL and non-CDL chronic medication costs Limited to R15 000 for a member and R30 000 for a family. condition medication will be
will be paid from the non-CDL limit first. Thereafter, CDL Subject to BESTmed formulary and medicine reference price.
chronic medication costs continue being paid by the Scheme.
Co-payment of 20% for non-formulary medicines.
paid at 100% of the BESTmed
*CDL chronic condition medicine 100% of BESTmed tariff is paid.
tariff, but you must obtain
Please note that CDL and non-CDL chronic medication costs Subject to BESTmed formulary and medicine reference price. pre-authorisation for all
will be paid from the non-CDL limit first. Thereafter, CDL Co-payment of 20% for non-formulary medicines.
chronic medication costs continue being paid by the Scheme. prescribed medicine by
Biological medicine Subject to pre-authorisation and limited to R300 000 per contacting 086 000 2378,
faxing 012 339 9944 or e-mailing
Acute medicine Limited to R5 000 for a member and R8 000 for a family.
A 10% co-payment is payable.
Subject to overall annual limit and medicine reference price.
Over-the-counter medicine Limited to R1 000 per family per year.
Subject to the acute medicine limit.
The medicine listed in the formulary for CDL South Africa, BESTmed will pay for the generic
chronic condition medication will be paid at 100% medicine up to the Mediscor Reference Price (MRP)
of the BESTmed tariff, but you must obtain for the active ingredient.
pre-authorisation for all prescribed medicine by
• The benefit amount for prescribed medicine
contacting 086 000 2378, faxing 012 339 9944 or
will be calculated at the Single Exit Price (SEP)
plus the dispensing fee (as determined by
Prescribed medicine will be reimbursed under the BESTmed) plus Value Added Tax (VAT), if
following conditions: applicable.
• Where medicines have generic alternatives • You may be required to obtain your medicine from a
registered with the Medicines Control Council of Designated Service Provider (DSP).
*Chronic medicine for Chronic Disease List (CDL) conditions
The reference price for medicine listed in the BESTmed formulary for the following 26 chronic conditions will be
paid provided you obtain pre-authorisation.
• Addison’s Disease • Dysrhythmias
• Asthma • Epilepsy
• Bipolar Mood Disorder • Glaucoma
• Bronchiectasis • Haemophilia
• Cardiac Failure • Hyperlipidaemia
• Cardiomyopathy • Hypertension
• Chronic Obstructive Pulmonary Disease • Hypothyroidism
• Chronic Renal Disease • Multiple Sclerosis
• Coronary Artery Disease • Parkinson’s Disease
• Crohn’s Disease • Rheumatoid Arthritis
• Diabetes Insipidus • Schizophrenia
• Diabetes Mellitus Type 1 • Systemic Lupus Erythematosus
• Diabetes Mellitus Type 2 • Ulcerative Colitis
**Chronic medicine for Chronic Disease List (CDL) conditions
The reference price for medicine listed in the BESTmed formulary for the following 45 non-CDL conditions will be
paid at 85% of the BESTmed tariff.
• Acne – Severe • Idiopathic Thrombocytopenic Pupura
• Allergic rhinitis • Major depression
• Alzheimer’s Disease • Migraine prophylaxis
• Ankylosing spondylitis • Motor Neuron Disease
• Aplastic anaemia • Muscular dystrophy and inherited myopathies
• Attention Deficit Disorder (ADD)/Attention Deficit • Myasthenia Gravis
Hyperactivity Disorder (ADHD) • Neuropathy
• Benign Prostatic Hypertrophy • Obsessive Compulsive Disorder
• Chronic anaemia • Osteoarthritis
• Collagen Disease • Osteoporosis
• Cushing’s Disease • Paget’s Disease
• Cystic Fibrosis • Paraplegia/Quadriplegia (medicine to treat)
• Dermatomyositis • Polyarteritis nodosa
• Eczema • Polycystic Ovarian Disease
• Endometriosis • Psoriasis
• Female menopause • Psoriatic arthritis
• Fibrosing alveolitis • Pulmonary Interstitial Fibrosis
• Gastro Oesophageal Reflux Disease • Pulmonary embolism
• Gout prophylaxis • Scleroderma
• Graves Disease • Sjogren’s Disease
• Hyperthyroidism • Stroke
• Hypophyseal adenoma • Trigeminal neuralgia
• Hypopituitarism • Urinary incontinence
Preventative Care Benefits
“Prevention is better than Benefit type Gender and age group Quantity and frequency Benefit criteria
cure. Pro-active health risk Influenza vaccine All ages One per beneficiary per year Applicable to all active members and beneficiaries.
management is better than Pneumonia Children < 2 years Once in 5 years Funding for children < 2 years:
Programme High risk adult group Parents to contact BESTmed in advance to pre-
paying for care. Benefits should arrange funding prior to obtaining the vaccine.
benefit the member, not the Funding for adults:
BESTmed will identify certain high risk individuals
disease. Put the health Rand who will be invited to be immunised.
where the health Risk is. Change Paediatric Funding for all paediatric vaccines according to the State recommended programme for babies and
the course of member claim
Oral contraceptives All females of child Monthly fills up to the Limited to R1 200 per family for the year.
history by changing the health bearing age maximum allowed amount Includes all items classified in category of oral
story of each member.”
Back rehabilitation All ages When required Applicable to beneficiaries that have serious
Dr C du Preez (MD) programme spinal or back problems and may require surgery.
(provided by BESTmed identifies appropriate participants
Documentation for evaluation at the DBC centre. Based on the
Based Care) outcomes of the evaluation, a rehabilitation
treatment plan is drawn up and initiated which
lasts approximately six weeks.
HIB titre Children 5 years and One vaccine at 6, 10 and If the booster vaccine was not administered
immunisation younger 14 weeks after birth timeously, the maximum age to which it will be
1 booster vaccine between allowed is 5 years.
Mammogram Females Once every 2 years Must be pre-authorised by BESTmed.
PAP smear Females older than Once per year To be done at a gynaecologist.
40 years Gynaecologist claim paid from the consultation
Preventative Care Benefits (continued)
Benefit type Gender and age group Quantity and frequency Benefit criteria
PSA test (Prostate Males older than 50 Once per year
Specific Antigen) years
Lipogram Beneficiaries older Once per year A lipogram is a cholesterol screening test to
than 45 years identify beneficiaries at high risk for heart disease.
Bone densitometry Females older than Once every two years Must be pre-authorised by BESTmed.
HIV test All ages One test per beneficiary One ELISA diagnostic test per beneficiary.
per year Western Blot diagnostic tests excluded from this
Benefit type Age Frequency
General full mouth examination by a Above 12 years Once a year
general dentist Under 12 years Twice a year
Full mouth intra-oral radiographs All ages Once every 3 years
Intra-oral radiographs All ages Two photos per year
Scaling and/or polishing All ages Twice a year
Fluoride treatment All ages Twice a year
Fissure sealing Up to and including 21 years In accordance with accepted protocol
Space maintainers During primary and mixed denture stage Once per space
“Full details of the HIV/AIDS Wellness Management Programmes approved treatment depends on the member’s clinical
results. The stage of the disease and the results of
programme and the benefits These programmes are aimed at managing your blood tests determine what treatment will be covered
wellbeing and treatment if for example, you:
offered will be provided to and how the member must be monitored.
members who register. You • Have cancer Full details of this programme and the benefits
• Are HIV positive or have AIDS offered will be provided to members who register.
can also find more on the
• Are pregnant, etc. You can also find more information on the BESTmed
BESTmed website under website under ‘Managed care’ or you can contact
You need to register on the relevant programme/s in 011 251 9400.
‘Managed care’ or you can order to receive the benefits.
contact 011 251 9400.” CDL chronic benefit
HIV/AIDS benefit management programme
BESTmed’s CDL chronic programme is run by qualified
BESTmed covers counselling and testing for members pharmacists and clinical staff who ensure that
who want to confirm their HIV status. appropriate, cost-effective and quality treatment is
You must be registered on the HIV/AIDS Benefit provided to members in terms of the Scheme Rules
Management Programme in order to receive benefits. and benefits.
Benefits for members, who are HIV positive, cover a You must apply for the CDL Chronic Benefit if you
spectrum of services, including: have been diagnosed with a chronic condition and will
• Advice and counselling from the HIV helpline. need treatment on an ongoing basis. Please call
086 000 2378 for more information on how to
• Regular blood tests to monitor disease progression
apply or go to www.bestmed.co.za and click on
and to measure the response to treatment.
‘Managed care’ and then on ‘Pharmaceutical Benefit
• Medication and anti-retrovirals (medicine to fight Management’.
• Where a pregnant mother is HIV positive, BestBaby
medication is provided to enable her to have
This programme has been designed to support
a natural delivery. Medication (known as post-
pregnant mothers throughout their pregnancy.
exposure prophylaxis) is also given to the new baby
A dedicated 24-hour emergency line with trained
to reduce the chances of infection.
medical personnel can guide members through
The treatment programme covered by BESTmed those sudden and unexpected occurrences during
is based on the HIV/AIDS funding guideline and pregnancy.
If a mother is regarded as a clinically high risk, her 24 Hour Emergency Evacuation “Full details of the Oncology
pregnancy will be monitored more closely by having
regular blood tests and blood pressure assessments. This includes emergency transportation by an Programme and the benefits
ambulance, response car, helicopter or fixed-wing offered will be provided to
The programme offers additional benefits such as aircraft, if for example, you are involved in a motor
free gifts and sonars to all members registered on the vehicle accident. This service is paid at 100% of the members who register on
programme. cost if rendered and pre-authorised by ER24. the programme. You can also
Full details of this programme and the benefits offered
will be provided to members who register. You can also International Travel Cover find more information on
find more information on the BESTmed website under the BESTmed website under
‘Managed care’ or you can contact 011 704 0072. If you are travelling overseas on holiday, you will enjoy
the cover provided by the International Travel Cover ‘Managed care’ or you can
benefit. Download the policy on www.bestmed.co.za
Oncology benefit management programme contact 012 339 3537.”
and keep it with you while you are away.
You must be registered on the Oncology Programme
in order to receive benefits. Broadly, the programme
offers: You must contact ER24 on 011 319 6300 to take
out additional insurance if:
• Access to additional benefits and services that
form part of the treatment protocol. • You are over the age of 80
• Oncology treatment that includes chemotherapy, • You will be travelling overseas for more than 90
radiation therapy, certain pathology, certain days
radiology and certain consultations. • You will be taking part in hazardous activities while
you are away
• All services must be pre-authorised by BESTmed. Emergency medical assistance when travelling
• Preferred providers may be appointed by BESTmed. To access emergency medical assistance when
• The services must fall within BESTmed’s funding you are on holiday internationally, please call
protocol. +27 010 205 3100. When the operator asks for
the name or number of your policy, please say ‘ER24
Full details of the Oncology Programme and the INTERNATIONAL TRAVEL EXTENSION’ and quote
benefits offered will be provided to members who your BESTmed membership number.
register on the programme. You can also find more
information on the BESTmed website under ‘Managed
care’ or you can contact 012 339 3537.
Prescribed Minimum Benefits Medical schemes may use certain risk management
tools to ensure that cover for PMBs are appropriate
What is a prescribed minimum benefit? and cost effective. Risk management tools used by
Prescribed Minimum Benefits (PMBs) are minimum
benefits which, by law, must be provided to all medical • Formularies (medicine lists)
scheme members. This includes the provision of • Clinical funding guidelines and treatment protocols
diagnosis, treatment and care costs for: • Pre-authorisation procedures
• A limited set of 270 conditions as specified in • Designated Service Providers (DSPs)
Annexure A of the Regulations to the Medical
Schemes Act (No. 131 of 1998). When are you eligible for a PMB?
• A list of 26 chronic conditions – also referred to as BESTmed reimburses a claim as a PMB when a
the Chronic Disease List (CDL). healthcare provider uses the appropriate diagnostic
• Any emergency condition. code (ICD-10 code) that corresponds to the published
list as per the Council for Medical Schemes. A list of
What is an emergency? these conditions and codes can be obtained from
the Council for Medical Schemes’ website at
A medical emergency is the sudden, unexpected www.medicalschemes.com.
onset of a health condition that needs immediate
medical or surgical treatment. If the treatment is not How are PMBs paid?
provided, then the person’s life would be at risk or
result in serious impairment or dysfunction of a bodily BESTmed will cover the diagnosis, treatment
organ or body part. and costs of PMBs in full, with no co-payment,
in accordance with the Scheme Rules, protocols
BESTmed covers you for in-hospital emergencies. In the and formularies. The ICD-10 code on the claim
event of an emergency, you must immediately go to provides BESTmed with the information to identify
a hospital for medical care, but remember to obtain an the treatment/s that should be paid as PMBs. It is
authorisation number within 48 hours of the consultation therefore essential that all accounts are submitted
or on the first working day after the consultation. with valid ICD-10 codes. This allows us to pay the
Section 29 of the Medical Schemes Act requires account from the correct PMB benefit.
medical schemes to stipulate the scope of minimum
benefits in its Scheme Rules. Please refer to the
registered Rules of BESTmed for further details.
PRE-AUTHORISATION • A child older than 21, but not older than 26, who is
studying and dependent on the member. Proof of
Must I Get Pre-Authorisation? registration to a registered tertiary institution will
Yes, before you go into hospital or have any surgery • Immediate family* for whom the member is legally
or diagnostic investigations you must obtain an liable to provide family care and support.
authorisation number from BESTmed by calling
0800 22 0106. • Other persons who are recognised by BESTmed as
In the event of a life-threatening emergency
* Immediate family refers to the member’s mother, father, brother or
admission after office hours or on weekends or public
sister. BESTmed will require proof of dependency and a late joiner
holidays, you must obtain an authorisation number on penalty may apply.
the first working day after the hospital admission. If
you do not pre-authorise a hospital visit, penalties will
be imposed for late authorisation.
The Medical Schemes Act allows medical schemes
Pre-authorisation is important as it helps to ensure
such as BESTmed to impose a waiting period on
that you and your service providers are aware of
benefits under certain circumstances. This means
what expenses will be paid by BESTmed. The pre-
that you will not be able to access a particular benefit
authorisation process includes the management of
for a specified period of time.
your stay and treatment in hospital.
There are two types of waiting periods:
For more information on pre-authorisation, please go
to www.bestmed.co.za and click on ‘Managed care’ • Condition-specific waiting period – this refers
and then on ‘Hospital Benefit Management’. to a specified period of time during which a
beneficiary cannot claim benefits for a condition
IMPORTANT ADMINISTRATIVE for which medical advice, diagnosis, care or
treatment was recommended or received within
the twelve-month period before the member
applied to join BESTmed.
Who Can Be a Dependant?
• General waiting period – this is a specified period
BESTmed recognises the following people as of time during which a beneficiary is not entitled to
dependants: claim any benefits.
• The member’s spouse or partner. If you are on chronic medication, you may be able to
• A child older than 21 if the child is dependent on claim for certain treatments or chronic medication
the member due to a mental or physical disability. covered under the Prescribed Minimum Benefits.
However, if you were not a member or dependant of How to Submit a Claim
a registered medical scheme for longer than 90 days
before joining BESTmed, you will not be able to claim Please submit the original claim directly to BESTmed
for certain treatments or chronic medication covered if your service provider does not submit claims. Make
under the Prescribed Minimum Benefits. sure that your personal details, membership number
and claiming details are correct before submitting the
• The following details must appear on all claims:
BESTmed benefits are calculated for a period of 12
“Claims can be scanned and months from 1 January to 31 December. If a member • Name and contact details of member
e-mailed to joins during the year, e.g. in May, the benefits can • BESTmed membership number
be calculated according to the number of months • Name and contact details as well as practice
firstname.lastname@example.org or remaining in the year. number of the service provider
posted to BESTmed Medical • Details of treatment, including applicable tariff and
Scheme, PO Box 2297, Arcadia, Late Joiner Penalty ICD-10 codes
Pretoria, 0001.” Late joiner penalties can be imposed on new members • Details of patient
over the age of 35. Depending on the number of years • Whether to pay the service provider or the member
where the member did not belong to a medical scheme,
a late joiner penalty will be added to the member’s Claims can be scanned and e-mailed to
monthly contribution. The penalty is calculated on a email@example.com or posted to BESTmed
sliding scale as shown in the table below, based on the Medical Scheme, PO Box 2297, Arcadia, Pretoria, 0001.
total number of years from age 35 where a member did You must submit the claim, with the necessary proof
not belong to a medical scheme. of payment, within four months of the treatment. If
your claim was not received within four months, your
Number of years since claim will be rejected and you will have to settle the
age 35 where applicant
was not a member of a
Penalty account yourself.
Claims are processed within 48 hours of receipt.
1 – 4 years 1.05 x contribution BESTmed has a claims payment run every Friday as
5 – 14 years 1.25 x contribution well as a month-end payment run (three working days
after the last day of the previous month).
15 – 24 years 1.5 x contribution
Money will be paid directly into your bank account
25+ years 1.75 x contribution
within seven working days of receipt of your claim.
Please remember to attach your proof of payment The online service provides you with access to your:
and that it is your responsibility to ensure that
• Personal details
BESTmed has your updated bank account details.
• Claims history
You will receive a mini statement via e-mail notifying • Process status of submitted claims
you the day after a claim was processed of the status
• Benefits available
of the claim - you can reply to the e-mail if you have
any queries regarding the claim/s. • Contributions paid
A complete claims statement (remittance advice)
is sent to you via e-mail or post after each claims
payment run. Please ensure that the details on the For a summary of your chronic medicine and
statement are correct. condition/s as registered, personal details and the
three most recent claims received and assessed, just
send a blank e-mail to firstname.lastname@example.org
ONLINE SERVICES and you will receive the information via e-mail from
us. Please ensure that BESTmed has your correct
How To Register Online e-mail address.
• Go to www.bestmed.co.za
• Click on ‘Online services’
• Click on the ‘Register’ link If you’d like to receive your BESTmed information
directly to your cell phone, depending on the
• Fill in the details as requested information you require, SMS either A, B or C to 31416.
• Click on ‘Complete’
A = Personal details
• You will receive an activation process form B = Summary of benefits available
• Please print, sign and fax the form to C = Confirmation of three most recent claims
012 339 9900
We will then activate your password when we
receive your fax and will notify you via e-mail once
this has been done. The next time you go to ‘Online
services’ you will be able to login using your BESTmed
General CDL Chronic Medication Website Technical Issues
Tel: 086 000 2378 Tel: 086 000 2378
e-mail: email@example.com e-mail: firstname.lastname@example.org
Fax: 012 323 4106 Fax: 012 339 9944
Regional SHDS Offices
Walk-in Facility ER 24 and International Travel Cover Sanlam Healthcare Distribution Services (SHDS) is the
551 Belvedere Street, Arcadia, Pretoria 084 124 marketing and distribution network of BESTmed.
Postal Address BestBaby Gauteng 080 028 7633
PO Box 2297, Arcadia, Pretoria 0001 Tel: 011 704 0072 Free State 086 010 5153
e-mail: email@example.com Western Cape 086 010 5154
Port Elizabeth 086 010 4950
HIV/AIDS Programme East London/Mthatha 086 010 4950
Tel: 086 000 2378
KwaZulu-Natal 086 010 9920
e-mail: firstname.lastname@example.org (queries) Tel: 011 251 9400
email@example.com (claim submissions) e-mail: firstname.lastname@example.org Mpumalanga 086 010 4950
email@example.com Limpopo 086 099 9633
Hospital Authorisation Fax: 086 500 9822
Tel: 0800 22 0106
BESTmed is administered by Sanlam, one of
Oncology Programme South Africa’s leading financial services groups,
Tel: 012 339 3537 with an enviable track record of providing
e-mail: firstname.lastname@example.org products and services that embody their values
of trust, honesty, integrity and caring. Like
Online Service Access and Queries Sanlam, BESTmed continually strives to offer the
best with value-for-money products supported
by superior client service to make your dealings
with BESTmed efficient and to your satisfaction.
Webmail (e-mail facility)
BESTmed dispensing fee The fee a pharmacist charges for dispensing medicine.
BESTmed tariff The price paid by BESTmed for a medical service provided.
Biological medicine Biological medicine is medicine that is derived from living sources, e.g. insulin
and growth hormones.
Chronic Disease List (CDL) A CDL is a list of chronic conditions where BESTmed will provide and pay for
medication and the treatment of the chronic condition. Refer to page 8 for the list.
Co-payment This is the portion of the total cost of a procedure or consultation that you must
pay directly to the service provider or, you may request it to be paid from the
available funds in your medical savings account.
Designated Service Provider (DSP) A regulated healthcare provider (facility or State operated service provider)
contracted by the Scheme to provide diagnosis, treatment and care in respect of
one or more conditions, to its members.
Formulary A formulary is a list of medicines that BESTmed will pay for to treat the chronic
conditions as per the option you have selected.
Maxilla-facial surgery Surgery to the jaw or jawbone.
Medical savings account Medical expenses are paid from your medical savings account, as stipulated per
your selected option. When your medical savings account has been exhausted,
you will pay for out-of-hospital expenses yourself. Any unused funds in your
medical savings account at the end of a benefit year will be carried over to the
next year. Should you resign from the Scheme in the duration of a benefit year,
the funds in your medical savings account will be paid back to you after a period
of four months.
Mediscor Reference Price (MRP) The MRP is a reference list of generic medicines that cost less than original
brand name products. MRP sets a maximum reimbursement price for each
generic product. This list is reviewed regularly to ensure that a comprehensive
range of affordable medicine is available. A change in the MRP will affect the
Non-CDL condition There are other chronic conditions which do not form part of the CDL.
Depending on the option you select, BESTmed may pay part or all of the
Pre-authorisation Giving approval for a medical event before it occurs.
Prescribed Minimum Benefit (PMB) A PMB is a benefit which, by law, must be provided by BESTmed to all its
members. This includes diagnosis, treatment and ongoing care costs.
Prosthesis An artificial part supplied to remedy a deficiency, e.g. leg, arm, etc.
Protocols Protocols are clinical guidelines, compiled by experts in the field of a specific
medical condition, which specify how a condition should be treated based on
best practice principles.
Single Exit Price (SEP) SEP refers to legislation mandating that medicine manufacturers may only sell
their products at one price to all their customers, regardless of the nature of
the customer’s order size and consumption levels. The term means that each
and every product and its variants ‘exits’ the factory at one single price for that
product or variant.
Specialised dentistry It is special dental procedures including root canals, gum surgery, oral surgery
Supplementary services This includes services rendered by dieticians, chiropractors and homeopaths
and for services including acupuncture, speech therapy, audiology, occupational
therapy, physiotherapy, etc.
Disclaimer: Whilst BESTmed has taken all reasonable care in
compiling this benefit guide, 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. The Scheme’s Rules is pending the Registrar’s approval.