blueprint2009
The BESTmed product offering The BESTmed product offering is extensive with seven options that meet the unique and individualistic healthcare needs of our members. We have taken great care and thought in designing our products by analysing the lifestyles, health profiles and socio-economic circumstances of our market. Our product offerings range from comprehensive cover for hospital as well as out-of-hospital services to products offering limited out-of-hospital benefits, but comprehensive in-hospital benefits. No matter the age, income or gender of your client we have the option that will suit your member the BEST! Product range The Product offerings differ from each other on the basis of the following criteria: Cover for hospital services; Cover for out-of-hospital services; Cover for chronic medicine; Freedom of choice with regard to service provider networks; Access to disease management programmes and preventative care; as well as Subscriptions (member fees). With regard to out-of-hospital cover the scheme distinguishes between products funding these services from a savings account and those funding these services from scheme benefits (cross subsidised benefits). = = Flexibility in the choice of provider Benefits More benefits More affordable
BLUEPRINT Blueprint is a capitation product that offers a wide range of benefits, such as 100% hospitalisation. This option also provides for unlimited primary healthcare services received from the chosen network, namely Carecross or Primecure. Who should be on Blueprint? Families or low income workers or students Members that prefer making use of the two provider networks Primecure or Carecross Full hospital cover HOSPITAL TREATMENT No overall annual limit Pre-authorisation required SCHEME BENEFIT APPLICABLE TARIFFS Accommodation (hospital stay) 100 % contracted fee Unlimited Theatre fees 100% contracted fee Unlimited BENEFIT AMOUNT To take home medicine 100% of cost Limited to 3 days medicine Treatment in mental health clinics 100% of scheme tariff 21 days per beneficiary Treatment of chemical and substance dependence/abuse Service to be obtained at Public facilities only 100% of cost PMB conditions only Consultations and procedures 100 % of scheme tariff Unlimited Surgical procedures and anaesthetics for surgical procedures and operations excluding dental operations Pathology and radiology (including MRI, CT Scans) Prosthesis Implanted Gynaecology / Urology Cardiovascular prosthesis Spinal prosthesis 100% of scheme tariff Unlimited 100 % of scheme tariff Unlimited 100% of cost Limited to R30 000 R 6000 R 20 000 R 20 000 Confinements 100 % of scheme tariff Unlimited Oncology Treatment Radiation and chemotherapy Service to be obtained at Public facilities only 100% of scheme tariff Unlimited
OUT-OF-HOSPITAL TREATMENT This option makes provision for unlimited primary healthcare services to be obtained from contracted service providers only as well as specialist services. PRIMARY HEALTHCARE SERVICES GP Consultations, treatment, diagnostic tests, injections, immunisation, pre and anti-natal examinations Out of network GP consultations Medicine Optical Benefits Conservative Dentistry (basic) Basic pathology tests BENEFIT DESCRIPTION Unlimited provided that services are obtained from the chosen network providers (Carecross or Primecure) Services are limited to treatment protocol of networks Two out of network visits per year per family provided that it is pre-authorised by BESTmed. BESTmed will pay in accordance to scheme tariffs up to R400 per visit Unlimited acute and chronic medicine provided that the chosen Primary Health Care provider prescribes it, it is included on the Network Provider s medicine formulary (medicine list), and is approved or authorised by the Network. Patients will obtain the medicine from designated pharmacies. Each beneficiary has access to the following during a period of 24 months: One Consultation and refraction test; One pair of glasses / spectacles; Single vision or Bi-focal lenses (nontinted) and A frame to be chosen from a limited range of frames; Glasses/ spectacles permitted, provided that eye test indicates that visual impairment is severe enough to warrant spectacles. Contact lenses and tinted lenses are not part of the benefit structure. The following basic services are covered: Consultations; Standard fillings and primary extractions; Fillings (levels 1-3, black) Above services should be received from a contracted dentist only. Obtain details about contracted dentists from BESTmed Basic blood and urine tests are included. All tests should be done either by the chosen practitioner, or a contracted pathologist as to be referred to by the chosen network practitioner.
Basic radiology tests SPECIALIST SERVICES Specialist consultations Unlimited Basic radiology X-rays only. Advanced radiology such as MRI or CT Scans is not covered. Basic X-rays should be taken only at the contracted radiologist as referred to by your chosen network General Practitioner. BENEFIT DESCRIPTION Each family has access to 3 consultations with specialists provided that pre-authorisation was obtained from BESTmed prior to the consultation and that the patient was referred by the chosen network service provider. BESTmed will pay in accordance to Scheme tariffs up to R780-00 per specialist visit. BLUEPRINT ADDITIONAL INFORMATION This option does not make provision for a savings account and all expenses not covered under hospital treatment, primary healthcare services or specialist services will not qualify for any benefit amount and will be for the members own account. CONTRIBUTIONS Income R0-12 000 p.a Risk Total Monthly Principal member R573 R573 Spouse/adult dependant R540 R540 Child R342 R342 Income R12 001-60 000 p.a. Risk Total Monthly Principal member R723 R723 Spouse/adult dependant R552 R552 Child R342 R342 Income R60 001 plus p.a Risk Total Monthly Principal member R804 R804 Spouse/adult dependant R615 R615 Child R342 R342
NOTES
DISEASE MANAGEMENT PROGRAMMES BLUEPRINT HIV/AIDS treatment Access to additional benefits and services to be received in Private facilities, as part of the services offered in the HIV/Aids management programme as provided and managed by Optipharm. Patients need to register on the HIV/Aids programme in order to qualify for these additional benefits and services. Tel: 012 339 9446/9824 BESTbaby programme Additional benefits and services to be included in the maternity programme that forms part of the BESTBaby programme. Tel: 086 111 1936 Health days Screening for potential serious diseases Vaccines Arranged at participating employer organisations Tel: 012 339 9440 Nurse line Information line Nursing sister, medical advisors Tel: 012 339 3637 Hospital benefit management Hospital pre-authorisation Case management Tel: 086 000 2387 Account auditing Authorisations: 0800 220 106
EXCELLENT ACCESS Post/Surface mail PO Box 2297, Arcadia, Pretoria, 0001 Physical address 551 Belvedere Street, Arcadia, Pretoria Tel: 012 339 9800 Fax: 012 339 9900 Call centre: 086 000 2378 or 086 000 BEST E-mail: service@bestmed.co.za Pre-authorisation 0800 22 0106 or authorisations@bestmed.co.za ER24 for ambulance emergency evacuation: 084 124 www.bestmed.co.za Regional offices Gauteng 080 028 7633 Free State 086 010 5153 Western Cape 086 010 5154 Port Elizabeth 086 010 5156 East London/ Mthatha 086 010 4950 KwaZulu-Natal 086 010 9920 Mpumalanga 086 010 4950 Limpopo 086 099 9633 Disclaimer: Whilst BESTmed has taken all reasonable care in compiling this summary, we cannot accept liability for any errors or omissions contained in it. Please note that should a dispute arise with regard to any benefit, the registered rules of BESTmed, subject to approval by the Registrar of Medical Schemes, shall prevail.