Some of the CDL, PMB and non-CDL chronic conditions require additional clinical information in order to qualify for registration. Before Bestmed can process the application, it’s necessary for them to receive a report from the appropriate treating specialist together with specific clinical information. The conditions where additional information is needed, including the specific information required for each chronic condition, are listed in the table below.

A formulary is a list of medicines we will cover, according to Scheme Rules, for the treatment of the listed chronic conditions per option.

It’s a diagnosis code, indicating the health condition for which treatment is being received and is, therefore, compulsory on all medicine applications and prescriptions.

CDL and PMB are lists of chronic conditions for which a scheme must provide cover for the medicine and treatment of the condition. Note: Option specific inclusions/exclusions may apply.

These are additional chronic conditions which may be covered by the Scheme, depending on the member’s chosen benefit option. It’s not compulsory for the Scheme to fund treatment of these conditions. Refer to the comparative guide covered per option.

For every CDL and PMB condition where medicine is approved, a basic treatment plan is provided. The treatment plan differs from condition to condition and can include consultations, pathology, diagnostic imaging, etc. For each approved service, there is a maximum allowed per year at specified interval periods over a 12-month period. These services are paid from the day-to-day limit first, where applicable. Once the limit is depleted, claims will continue to be paid from Scheme risk up to the maximum quantity specified in the treatment plan. The treatment plan allocations are reset in January every year.

If a member has a general three- (3-) month waiting period, they are entitled to apply for CDL chronic and PMB benefits. If a member has a 12-month condition-specific exclusion, then the member cannot claim for any services related to that condition for a period of 12 months.

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.

Call +27 (0)86 000 2378 or click here to obtain an application form. Completed application forms can be sent by fax to +27 (0)12 472 6760 or emailed to medicine@bestmed.co.za.

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 Mediscor reference price (MRP) to set the generic reference price. A member can use the original medicine and pay the difference between the price of the chosen medicine and that of MRP (thus have a generic co-payment). Alternatively, the member can use a generic alternative within the reference price range and have no generic co-payment. Reference pricing is applicable to all medicines, including formulary and non-formulary chronic medicines, as well as acute and OTC medicines.

A co-payment is the portion of a claim payable by the member directly to the service provider.

• When the medicine being used is not on the medicine formulary
• If the medicine being used is more expensive than the reference price
• When the provider charges a higher dispensing fee than that which the Scheme reimburses
• Approved non-CDL formulary medicine has a standard co-payment for specific options as defined in the Scheme rules

You need to submit a copy of the member’s prescription and membership details by email to medicine@bestmed.co.za or fax to +27 (0)12 472 6760.

A patient should only submit their prescription to Bestmed if their medicine has changed or if their authorisation is about to expire. However, the pharmacy will require a new repeat prescription every six (6) months in order to dispense their medicine.

Bestmed applies protocols and funding guidelines in their authorisation process. Should a member’s requested treatment fall outside of these funding guidelines, it will not be approved.

Chronic medicine claims can be submitted every 24 days.

The Medicine Supply advance application form should be completed and returned to Bestmed at least two weeks prior to the date of medicine collection:

• The information can be emailed to medicine@bestmed.co.za or faxed to +27 (0)12 472 6760
• Please attach a copy of the flight ticket or travel document to the application
• Please attach a copy of the prescription for the medicine required for collection
• Once the information is received, the member will be contacted within 48 hours via email

A preferred provider is a pharmacy recommended for Bestmed members to obtain their medicine. Any pharmacy that charges a dispensing fee of no more than 33% (with a maximum of R33 excl. VAT) and charges no additional administration fees, can be regarded as a preferred provider.

Bestmed has negotiated with more than 1 300 pharmacies and has compiled a list of these preferred providers who will charge a dispensing fee the same as or lower than the Bestmed fee structure. Patients are advised to obtain their medicine from one of these preferred providers to avoid any dispensing fee co-payments. A complete list of these providers can be viewed under Pharmacies here .

If a member wants to apply for a specific service to be evaluated and approved from the PMB risk pool the following must be kept in mind:

• Only qualifying PMB ICD-10 codes will be considered for PMB benefits
• The Bestmed PMB application form has to be completed by the treating provider, as well as the member for this request to be considered for PMB benefits and the necessary clinical supporting documents need to be submitted
• If all the PMB criteria have been met, funding for PMBs firstly come from the available day-to-day benefits and only thereafter the difference will be covered as a PMB

The PMB application can be requested by contacting the Bestmed contact centre. This PMB application request form must be signed by both the member and provider and, if a dispute arises, further information may be requested by the Scheme. Bestmed’s decision-making is based on the relevant treatment algorithms of the PMB regulations, Scheme protocols, Scheme Rules, formularies and other managed care initiatives.

Once a decision is made by the PMB department, both the member and provider will be informed of the outcome of the PMB application request via email.

For any application received, an email will be sent to the practice, as well as the member, informing them of the decision that has been made by the PMB department.

If an application has been approved for retrospective services, Bestmed will arrange for the claim/s to be processed from the PMB benefit. Members will be able to view all corrections to claims on the emailed and/or posted claims statement.

The form is available from Bestmed’s contact centre at +27 (0)86 000 2378, by emailing a request to pmb@bestmed.co.za or sending a request by fax to +27 (0)12 472 6760.

A medical emergency is the sudden, unexpected onset of a health condition which needs immediate medical or surgical treatment. If the treatment is not provided, the person’s life would be at risk or result in serious impairment or dysfunction of a bodily organ or body part.

Bestmed covers patients for in-hospital emergencies. In the event of an emergency, the patient must immediately go to a hospital for medical care, but must remember to obtain an authorisation number within 48 hours of the consultation or on the first working day after the consultation.

Section 29 of the Medical Schemes Act requires medical schemes to stipulate the scope of minimum benefits in its Scheme Rules. Please refer to the registered Rules of Bestmed for further details.

The term specialised diagnostic imaging is used for scans and include all types of scans such as Computed Tomography (CT) scans, Magnetic Resonance Imaging (MRI) scans and Positron Emission Tomography (PET) scans. All of these services must be pre-authorised in order for the Scheme to cover the associated expenses.

The member, dependant, a family member with the necessary information, the radiologists’ rooms or referring provider can call in to obtain an authorisation number. Clinical information to support or motivate the application for funding will be required in order for authorisation to be granted (this information is usually supplied by the referring provider).

• The patient’s member number
• Name of member or beneficiary and date of birth
• Date of CT/MRI/PET scan
• Name of the treating specialist/referring specialist and the practice number
• Name of the radiologist and practice number
• The reason for the CT/MRI/PET scan
• The ICD-10 code/s
• Tariff codes to be used for the CT/MRI/PET scan