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Claims

How to claim

Once you have made a payment, you can submit a claim via, e-mail, courier service, the Bestmed app, fax or post.

Claims are assessed the day they are received, and payment takes place during the weekly payment run.

Once payment has been made, members and providers will then receive a detailed statement.

How are claims assessed?

Bestmed’s Medicine Benefits includes the following categories:

Note: Benefits mentioned below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP).

  • Acute Medicine
    Reimbursement Criteria: Paid from savings or day-to-day benefit depending on your Bestmed option. Subject to a formulary (Pulse1 only). Co-payment applicable to Pace4
  • Over-the-counter medicine
    Reimbursement Criteria: Paid from savings or OTC benefit depending on your Bestmed option
  • Chronic Disease List (CDL) and Prescribed Minimum Benefit (PMB) medicine

    Reimbursement Criteria: Approved CDL/PMB chronic medicine costs will be paid from the non-CDL chronic medicine limit first (on applicable benefit options) thereafter, approved CDL/PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk

  • Non-CDL chronic medicine

    Reimbursement Criteria: Only applicable on certain Bestmed options. Approved non-CDL chronic medicine costs will be paid from the non-CDL chronic medicine limit

  • Biologicals and other high cost medicine

    Reimbursement Criteria: Approved PMB biological and non-PMB biological medicine costs will be paid from the biological limit first (on applicable options). Once the limit is depleted, only PMB biological medicine costs will continue to be paid unlimited from Scheme risk

  • Co-payments

    This is the portion of a claim that a member must pay out of pocket directly to the service provider.

    Co-payments may apply in the following scenarios:

    • Where a medicine is chosen for the treatment of a CDL, non-CDL or PMB condition that is not on the formulary
    • Where the chosen medicine is above MRP
    • When the provider charges a higher dispensing fee than that which the Scheme reimburses

    Members can avoid co-payments if they adhere to the Bestmed formulary medicines and network pharmacies. Co-payments are dependent on the Bestmed option. Please refer to the table below.

BENEFIT Non-formulary co-payment for CDL and PMB medicine Formulary co-payment for Non-CDL conditions Non-formulary co-payment for Non-CDL conditions
BEAT1 / BEAT1 N 40% N/A N/A
BEAT2 / BEAT2 N 40%
N/A
N/A
BEAT3 / BEAT3 N 40% 20%
35%
BEAT4 30% 10% 25%
PACE 1 35% 10% 30% 
PACE 2 30% 10% 25%
PACE 3 25% 10% 20%
PACE4 20%
10% 15% 
PULSE 1 40%  N/A N/A
PULSE2 25% 10% 20%

Pharmacies

Bestmed Network Pharmacies
DSP Pharmacies

These are pharmacies that have committed to proving cost-effective medicines at competitive dispensing fees which are capped at a lower level than non-network pharmacies.

Our DSP pharmacies are:

Glossary

Acute Medicine:
Medicine prescribed by any medical practitioner qualified to do so and is used for a short period of time.

Biologicals and other high cost medicine:
Medicines that are manufactured or derived from a living source.

Chronic Disease List (CDL) and Prescribed Minimum Benefit (PMB) medicine:
Medicine used for the treatment of the 26 CDL’s and the PMB conditions requiring medical management.

Co-payments:
This is the portion of a claim that you must pay out of pocket directly to the service provider.

Formularies:
A formulary is a pre-determined list of medicines. These lists of covered medicines vary from option-to-option.

Generics:
A generic medicine is one 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 similarly approved by the South African Medicines Control Council (MCC). Generics must have the same quality and produce an equivalent effect on the body as the original medicine. Always remember to ask for generics when obtaining medicine from your provider as they are more affordable than the original medicine will help you to extend your benefits.

Non-CDL chronic medicine:
Medicine for the treatment of additional chronic conditions which may be covered by the Scheme.

Mediscor Reference Price (MRP):
A generic reference price is a maximum set price a medical scheme is prepared to pay for a specific generic molecule for a specific dosage. Bestmed uses the MRP to set the generic reference price. This allows the prescriber and the member a choice, if they want to use a specific brand. 

Over-the-Counter- Medicine:
Medicine that can be obtained from a pharmacy for self0medication purposes that do not require a prescription.