The CDL is a list of chronic illness conditions for which a Scheme must provide cover for the medicine and treatment. These are conditions such as hypertension, asthma and diabetes.
Non-CDL conditions are additional chronic conditions which may be covered by the Scheme, depending on the chosen benefit option. It is not compulsory for the Scheme to fund treatment of these conditions. These are conditions such as gout and acne. Refer to the Comparative Guide for the list of conditions covered per option.
PMBs is a set of minimum benefits which, by law, must be provided to all medical Scheme members and include the provision of diagnosis, treatment and costs of ongoing care.
A formulary is a pre-determined list of medicines that will be covered for the CDL, non-CDL and PMB conditions. These lists of covered medicines vary from option to option. Bestmed makes use of formularies for each condition. These formularies are compiled and maintained by a team of professionals on the basis of evidence-based medicine, considering cost effectiveness and affordability.
Bestmed allows flexibility in terms of every member and dependant’s choice of medicine. If a member chooses to make use of a product that is not on the formulary, a co-payment will be applicable. This co-payment varies between the different benefit options, and forms part of Bestmed’s Scheme Rules.
An ICD-10 code is a diagnosis code, indicating the illness condition for which treatment is being received and is, therefore, compulsory on all medicine applications and prescriptions.
|Prescription required from endocrinologist or physician
|Prescription required from a rheumatologist or physician
|Most recent laboratory report required
|Mini-mental state examination (MMSE) required together with a prescription
|Prescription required from a paediatrician, paediatric neurologist or child psychiatrist
|Prescription required from a neurologist together with a motivation
|Bronchiectasis, cystic fibrosis and pulmonary interstitial fibrosis
|Prescription required from a pulmonologist or physician, or a paediatrician (in the case of a child)
|Collagen disease/scleroderma and Paget’s disease
|Prescription required from a physician
|Crohn’s disease and ulcerative colitis
|Prescription required from a gastroenterologist or physician together with motivation and supporting documentation
|Chronic obstructive pulmonary disease (COPD)
|Lung function test (LFT) report is required, which includes the FEV1/FVC and FEV1 post bronchodilator use.
|Chronic renal disease
|Application form must be completed by a nephrologist or physician. Attach supporting laboratory reports
|Diabetes mellitus (Type 2)
Submit HbA1c blood test results and/or fasting blood glucose results, pre-treatment value and current values
|Application form must be completed by an endocrinologist or physician
|EEG report must be submitted with the application or a prescription from the neurologist is required or a paediatrician (in the case of a child)
|Prescription required from physician. For initial applications: attach a laboratory report, reflecting factor VIII or IX levels. For medicine fill release: dosing chart is required.
|Lipogram results required
|Prescription required from a neurologist together with supporting scans for initial applications. Attach a report from a neurologist for applications for biologicals indicating:
a. Relapsing – remitting history
b. Extended disability status score (EDSS)
|Most recent bone mineral density (BMD) test results required
For initial applications:
For extensions: Compliance report with meter readings
|Polyarteritis nodosa/psoriatic arthritis and Sjogren’s syndrome
|Application form must be completed by a rheumatologist or physician
|Prescription is required from a psychiatrist. A family practitioner may prescribe the following active ingredients: fluoxetine, citalopram, escitalopram and tricyclic anti-depressants
|Prescription required from a rheumatologist. A family practitioner may also submit a prescription together with the pathology report
For every CDL and PMB chronic condition, where medicine is approved, there is a basic treatment plan that is also loaded. The treatment plan differs from condition to condition and can include consultations, pathology and radiology. These services are paid from Scheme benefits and not from the savings account. For each approved service, there is a maximum allowed per year.
How are claims paid for a treatment plan?
A biological is a substance that is made from a living organism or its products and is used in the prevention, diagnosis or treatment of diseases and chronic conditions.
Yes, but it depends on the chosen option, as well as the condition. Biological medicines are categorised as PMB biologicals and non-PMB biologicals. Approved PMB biological and non-PMB biological medicine costs will be paid from the biological limit first, on the options that have a biological limit (Pace2, Pace3 and Pace4). Once this limit is depleted, only PMB biological medicine costs will continue to be paid, unlimited, from Scheme risk.
If a member has a general three-month waiting period, the member is entitled to apply for CDL and PMB chronic benefits.
If a member has a 12-month condition specific exclusion, the member cannot apply or claim for any services relating to that condition for a period of 12 months. The member can also not apply for a PMB benefit if it relates to the specific condition.
No. To access the chronic benefit, pre-authorisation is compulsory. Thus, it is the member’s responsibility to apply for chronic benefits.
The member and the treating doctor will be required to complete a chronic medicine application form. It is advisable that one presents the treating doctor with a copy of the medicine formulary as it applies to the specific Bestmed Scheme option and the specific chronic condition.
Once a complete application is received by Bestmed, processing takes approximately two to three working days.
Yes, only if the member is already registered on the Bestmed system for chronic medicine. If not, the doctor will need to complete the chronic application form with the relevant supporting documentation, where needed.
When doctors call in and complete a telephonic prescription with one of Bestmed’s pharmacists, it is seen as a legal prescription as the call is recorded. This will not be applicable to pharmacists calling from a dispensing pharmacy as they are not the prescriber.
Approved CDL, non-CDL and PMB medicine costs will be paid from the non-CDL chronic medicine limit first. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
Chronic benefits will only be granted from the date the completed application/prescription is received. No retrospective authorisations will be granted.
A generic medicine is a medicine that contains identical amounts of the same active ingredient in the same strength and in the same dosage form as the original medicine. Generic medicines are approved by the South African Health Products Regulatory Authority (SAHPRA), and must have the same quality and produce an equivalent effect in the body as the original medicine. Benefits of using generic medicines:
The Mediscor Reference Price (MRP) is a reference pricing model applicable to all medicines with generic equivalents or biosimilars. MRP sets the maximum reimbursable price for generically similar or biosimilar products. This means that if you opt to use a medicine above MRP, you will have to pay the difference between the selected medicine and that of MRP. Reference pricing is applicable to all medicines, including formulary and non-formulary chronic medicines, as well as acute and over-the-counter (OTC) medicines.
A biosimilar is a biologic medical product that is almost an identical copy of an original product that is manufactured by a different company.
Should you prefer to use the original product, Bestmed will only reimburse the claim up to the MRP amount. Thus, you will be responsible for the difference in price payable to the provider.
This is the portion of a claim that a member must pay out of pocket directly to the service provider. This co-payment cannot be paid automatically from the available savings account or vested savings account.
Chronic Co-Payments 2023/2024
The MRP is reviewed and updated on a regular basis, and is dependent on the availability of generic medicines, as well as new generics entering the market. Thus, the change in MRP can affect the co-payment amount.
Bestmed applies protocols and funding guidelines in their authorisation process. Should your requested treatment fall outside of these funding guidelines, it will not be approved.
You need to submit a copy of your new prescription, including the ICD-10 code together with your member number to firstname.lastname@example.org or fax 012 472 6760.
One month prior to the date your medicine authorization expires, you must submit a copy of your latest prescription, including the ICD-10 code, with your member number to email@example.com or fax 012 472 6760.
Please submit your renewed script timeously to Bestmed to ensure correct payment of claims as no retrospective authorisations will be granted.
Additional information is required with the prescription for:
You should only submit your prescription to Bestmed if your medicine has changed or if your authorisation is about to expire. However, your pharmacy will require a new repeat prescription every six months in order to dispense your medicine.
Chronic medicine claims can be submitted every 24 days.
a. Approval conditions
Bestmed can grant approval for a member to claim for an advanced supply of medicine in the following instances:
b. Approval process
This information can be emailed to firstname.lastname@example.org or faxed to 012 472 6760.
These are pharmacies that have committed to providing cost-effective medicines at competitive dispensing fees which are capped at a lower level than non-network pharmacies. Any pharmacy that charges a dispensing fee of not more than 33% with a maximum of R33 (excl. VAT), and charges no additional administration fees, can be regarded as a preferred provider. You are advised to obtain your medicine from one of these preferred providers to avoid any dispensing fee co-payments.
Yes, medicine can be delivered to you by any postal pharmacy of your choice. Please refer to the preferred providers list to avoid any dispensing fee co-payments.
Tel: 086 000 2378
Fax: 012 472 6760