Bestmed Pulse 1C medical aid plan: 2019

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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 C
2018 Costs:
Total Cost pm:

Main member:

R1,976

Adult:

R1,777

Child: (Pay for all)

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

Main member:

R2,152
(8.91%)

Adult:

R1,937

Child: (Pay for all)

R1076
Savings (per year):
  • No savings option on this plan
Income band:
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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 C
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:
  • Choose from Network hospitals, or pay R10,750 co-payment if you voluntarily choose another hospital
  • No extra benefit
Specialised Radiology:
  • 100% scheme rate
  • No extra benefit necessary
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
Transplants:
  • PMBs only
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments:
    You or your gap cover pay R3,440co-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:
  • No benefit, unless PMB
  • 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, parkinsonism 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)
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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.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Pulse 1 C
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 a lot of 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:
  • Contracted Pulse1 GPs: unlimited
  • Not-contracted GPs: R1,290 per family
  • No extra benefit available
Childcare:
  • No extra benefits
  • No extra benefit available
Specialists consultations:
  • Must be referred, pre-approved and only at Bestmed Specialist DSP
  • Limited to R1,075 per person and R1,613 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 benefit, unless PMB
  • No extra benefit available
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
  • No extra benefit available
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MATERNITY BENEFITS:
Pulse 1 C
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
Consultations:
    Paid by Bestmed:
  • 9 consults, at GP/gynae/midwife
  • 4 x 2D specific scans
  • Iron and folic acid supplements
  • Post natal consult with GP/gynae/midwife
  • No extra benefit available
Scans:
    Bestmed pays for:
  • 4 scans
  • No extra benefit available
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CANCER (ONCOLOGY):
Pulse 1 C
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • PMBs only, at DSP (designated service provider)
  • 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
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DENTISTRY:
Pulse 1 C
Scheme Benefits Gap benefits
Standard Dentistry:
  • Standard dentistry: subject to network provider and protocols
Specialised Dentistry:
  • Specialised dentistry: no benefit
  • 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)
In-Hospital Dentistry:
  • Dental and oral surgery: no benefit, unless PMB
Orthodontics:
  • No benefit
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)
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MEDICATION:
Pulse 1 C
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary: 40%
  • No extra benefit available
Acute (presrcibed) medication:
  • Paid by Bestmed if on medicine list ("provider network formulary")
  • No extra benefit available
Over-the-counter:
  • R350 per family, subject to formulary (Bestmed's medicine list)
  • No extra benefit available
Birth Control:
  • R2,097 per family per year, paid by Bestmed
  • No extra benefit available
On Discharge:
  • 3 days
  • No extra benefit available
Biological:
  • No benefit, unless PMB level of care
  • No extra benefit available
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OPTOMETRY:
Pulse 1 C
Scheme Benefits Gap benefits
Optometry:
Limit:Paid by scheme, every 24 months
Consult:1 per person
Frames:R225
Single lenses100% cost
Bifocals:
Multifocals
Contacts
Refractive Surgery:no benefit
Notes:Above benefits from network provider
  • 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)
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MENTAL HEALTH:
Pulse 1 C
Scheme Benefits Gap benefits
In-hospital:
  • In-hospital: PMBs always paid in full at DSP, and include up to 21 days admission
  • Treatment of chemical or substance abuse: PMB level of care
  • No extra benefit available
  • (PMBs are paid in full by scheme if you use DSP)
Out-of-hospital:
  • Out-of-hospital: PMBs always paid in full at DSP, and include consultations
  • Otherwise, limited to R1,000 per person and R1,500 per family, paid from day-to-day benfit and shared with GP and Specialist benefits
  • 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)
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OTHER BENEFITS:
Pulse 1 C
Scheme Benefits Gap benefits
General Appliances:
    Out of hospital,
  • you pay this out of pocket
  • In-hospital, 100% scheme rate up to R5,913 per family
  • 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, which includes pathology tests, doctor consults, medicine and hospital treatment]
  • No benefit
Emergency Transport:
  • ER24
  • No benefit
International Insurance:
    In brief (all subject to conditions of policy):
  • Available to all members between the age of 3 months and 84 years old
  • Medical expenses up to R10 million. Pre-existing conditions or sequelae thereof limited to R250,000
  • Cost of a visit by a family member when severe illness or injury has occurred
  • Return to South Africa, if deemed necessary
  • No benefit
Other:
  • No benefit, unless PMB
  • No extra benefit available
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WELLNESS/PREVENTATIVE BENEFITS:
Pulse 1 C
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • Twice in a lifetime, with a booster above 65yrs
  • No benefit
Back Rehabilitation Programme:
  • 6 weeks, once a year
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • No benefit, unless PMB
  • No benefit
Mammogram:
  • No benefit, unless PMB
  • No benefit
PAS Test:
  • No benefit, unless PMB
  • No benefit
HIV Test:
  • No benefit
Other:
  • HPV Vaccinations
  • No benefit
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PROSTHETICS:
Pulse 1 C
Scheme Benefits Gap benefits
Overal Limit:
  • Internal: R48,053 per family
  • External: no benefit
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits:
    (per person):
  • Functional (treating or supporting a bodily function): R10,213
  • Vascular: R23,811
  • Pacemaker, dual chamber: R38,915
  • Spinal: R23,811
  • Mesh: R8,708
  • Gynaecology/Urology: R7,192
  • Lens implants: R5,000per lens
    Exclusions:
  • Endovascular and catheter-based procedures
  • Artificial disk
  • Drug eluting stents
  • Joint replacements, unless PMB
    PMB joint replacements - prothesis limits:
  • Hip replacement and other major joints: R24,403
  • Knee replacement: R30,853
  • Minor Joints: R11,556
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
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    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