Bestmed Pulse 1B medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

Pulse 1 B
2018 Costs:
Total Cost pm:

Main member:

R1,645

Adult:

R1,565

Child: (Pay for all)

R987
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

Child: (Pay for all)

R
Income band:
In brief (2018):
  • Scheme rate is 100%, and most day-to-day expenses are paid by scheme, or from out of pocket, unless PMBs
  • This plan has co-payments and exclusions for some procedures
  • You must use a Network DSP hospital
  • Bestmed pays for some out of hospital expenses, including unlimited GPs, optometry and dentistry
  • Cancer (PMB only) is treated in state hospitals, but you can upgrade to higher plan on cancer diagnosis to receive private hospital treatment
  • Cover for 27 chronic conditions
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
See full benefits below

IN HOSPITAL PROCEDURES:
Pulse 1 B
Scheme Benefits: Gap Benefits:
Specialists:
  • Up to 100% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Network hospitals, or up to R10,000 co-payment if you voluntarily choose another hospital
  • No extra benefit
Specialised Radiology:
  • 100% scheme rate
  • No extra benefit necessary
Supplementary Services: (Physio, etc)
  • Bestmed pays up to 100% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
Transplants:
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments:
    You or your gap cover pay R3,200 co-payment for:
  • Private hospital endoscopic procedures
  • Laparoscopic procedures
  • Prostate Procedures
  • Procedures for prolapse/incontinence
  • Arthroscopy, other than acute trauma
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • Bestmed pays up to 100% scheme rate
  • You pay the balance, if any
  • No extra benefit available
Casualty:
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
    Bestmed does not pay for:
  • Functional nasal surgery
  • Surgery for medical conditions e.g epilepsy, Parkinson's Disease etc
  • Procedures where stimulators are used
  • No benefit for exclusions
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

No phone calls!
Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

.
.
.
.
OUT OF HOSPITAL BENEFITS (non-PMB):
Pulse 1 B
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • This plan does not have a savings fund, but most out of hospital costs are paid by Bestmed, if you use their network providers
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • If you use a network GP, your consults are unlimited
  • For out-of-network GPs, you are limited to R1,200 per family
  • No extra benefit available
Childcare:
  • No extra benefits
  • No extra benefit available
Specialists consultations:
  • You can see a network specialists for 3 consults , limited to R1,000 per person and R1,500 per family
  • No extra benefit available
Pathology:
  • Paid by Bestmed if network is used, subject to protocols
  • No extra benefit available
General radiology:
  • Paid by Bestmed if network is used, subject to protocols
  • No extra benefit available
Specialised radiology:
  • No extra benefit available
Supplementary Services: (Physio, etc)
  • No extra benefit available

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MATERNITY BENEFITS:
Pulse 1 B
Scheme Benefits Gap benefits
Hospital stay:
  • Bestmed pays up to its scheme rate, includiing for births with midwife
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
Consultations:
  • Paid by Bestmed if you use network and follow protocols
  • No extra benefit available
Scans:
  • Paid by Bestmed if you use network and follow protocols
  • No extra benefit available

No phone calls!
Our quote will include the right gap cover for this plan

.
.
CANCER (ONCOLOGY):
Pulse 1 B
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Bestmed will pay for cancer treatment in a state hospital only, and only for PMBs. What does this mean?
  • If you are diagnosed with cancer while on this plan, you can upgrade your plan immediately to receive cover at private hospital
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, the gap cancer benefit will cover costs authorised but not paid by your medical scheme (up to the R150,000 per person per year gap limit) More info

No phone calls!
Our quote will include the right gap cover for this plan

.
.
DENTISTRY:
Pulse 1 B
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: subject to network provider and protocols
  • Specialised dentistry: no benefit
  • PMB conditions (eg. fracture of face bones, orbit or/and jaw) are always paid by schemes. More info on PMBs
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)
Orthodontics:
  • You pay this out of pocket
  • No extra benefit available
Maxillo Facial Surgery:
  • You pay this out of pocket, unless it's to treat a PMB.
  • PMB conditions (eg. fracture of face bones, orbit or/and jaw) are always paid by schemes. More info on PMBs
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MEDICATION:
Pulse 1 B
Scheme Benefits Gap benefits
Chronic:
  • All medical aid plans pay for treatment of the 27 CDL conditions as required by law. This includes medicine as well as GP or specialist consults, tests etc. Find out more
  • If you voluntarily use a PMB medicine that is not on Bestmed's list ("formulary"), you pay a 40% co-payment
  • No extra benefit available
Acute (presrcibed) medication:
  • Paid by Bestmed if part of medicine list ("formulary")
  • No extra benefit available
Over-the-counter:
  • R350 per family
  • No extra benefit available
Birth Control:
  • R1,950 per family per year, paid by Bestmed
  • No extra benefit available
On Discharge:
  • 3 days
  • No extra benefit available
Biological:
  • You pay this out of pocket
  • No extra benefit available

No phone calls!
Our quote will include the right gap cover for this plan

.
.
OPTOMETRY:
Pulse 1 B
Scheme Benefits Gap benefits
Optometry:
  • Consultation at PPN providers (includes Torga and Specsavers )
  • Frame: R150
  • Lenses: Single R175 or Bifocal R380 or Multifocal R380
  • Contact lenses: R555
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MENTAL HEALTH:
Pulse 1 B
Scheme Benefits Gap benefits
In-hospital:
  • Bestmed will pay for up to 21 days per person at 100% scheme rate, and may require use of specific providers
  • Cover for PMB mental conditions is always paid for by scheme, in and out of hospital. See full list here
  • No extra benefit available
  • (PMBs are paid in full by scheme if you use DSP)
Out-of-hospital:
  • Cover for PMB mental conditions is always paid for by scheme, in and out of hospital. See full list here
  • Otherwise, limited to R1,000 per person and R1,500 per family, in network
  • Shared with GP and specialist benefit
  • No extra benefit available
  • (PMBs are paid in full by scheme if you use DSP)
Trauma:
  • PMB conditions are covered for in and out of hospital treatment. For a full list see here.
  • Example of PMB condition: Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts
  • No extra benefit available
  • (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
OTHER BENEFITS:
Pulse 1 B
Scheme Benefits Gap benefits
General Appliances:
    Out of hospital,
  • you pay this out of pocket
  • No benefit
1.1. Hearing Aids:
  • You pay this out of pocket
  • No benefit
1.2. Wheelchairs:
  • You pay this out of pocket
  • No benefit
Dialysis:
  • Bestmed only pays for PMB cases, with a designated network provider
  • No extra benefit available
  • (PMBs are paid in full by scheme if you use DSP)
HIV:
  • Managed care programme
  • No benefit
Emergency Transport:
  • ER24
  • No benefit
International Insurance: TBC
  • No benefit
Other:
  • No benefit
  • No extra benefit available

No phone calls!
Our quote will include the right gap cover for this plan

.
.
WELLNESS/PREVENTATIVE BENEFITS:
Pulse 1 B
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • Covered
  • No benefit
Back Rehabilitation Programme:
  • No benefit
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • No benefit
  • No benefit
Mammogram:
  • No benefit
  • No benefit
PAS Test:
  • No benefit
  • No benefit
HIV Test: TBC
  • No benefit
Other:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
PROSTHETICS:
Pulse 1 B
Scheme Benefits Gap benefits
Overal Limit:
  • Internal: R44,700 per family
  • External: no benefit
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits:
  • Functional (treating or supporting a bodily function): R9,500
  • Vascular: R22,150
  • Pacemaker, dual chamber: R36,200
  • Spinal: R22,150
  • Mesh: R8,100
  • Gynaecology/Urology: R6,690
  • Lens implants: R4,650 per lens
    Exclusions:
  • Endovascular and catheter-based procedures
  • Artificial disk
  • Drug eluting stents
  • Joint replacements, unless PMB
    PMB joint replacements:
  • Hip replacement and other major joints: R22,700
  • Knee replacement: R28,700
  • Minor Joints: R10,750
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid

No phone calls!
Our quote will include the right gap cover for this plan


    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised