Bestmed Pulse 2 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 2
2018 Costs:
Total Cost pm:

Main member:

R4,732

Adult:

R4,732

Child: (Pay only for first 4)

R1,124
Savings Account:
  • No savings option on this plan
Extended Fund: RM= R12,250
M1+= R24,350
R R
2019 Costs:
Total Cost pm:

Main member:

R5,298
(11.96%)

Adult:

R5,298

Child: (Pay only for first 4)

R1,124
Savings (per year):
  • No savings option on this plan
Extended Fund: RM= R13,168
M1+= R26,176
R R
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In brief (2018):
  • Scheme rate is 100%, (gap increases this to 500%)
  • You must use a Network DSP hospital
  • Bestmed pays for some out of hospital expenses, including unlimited GPs, optometry and dentistry
  • Bestmed pays for some maternity consults and scans
  • Bestmed pays for refractive surgery
  • Treatment and medicine for 42 chronic conditions covered by scheme
  • There is a benefit for out-of-hospital specialised radiology
  • 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 2
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:
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments:
  • None
  • No extra benefit necessary
Alternatives to hospitals:
  • Bestmed pays up to 100% scheme rate
  • You pay the balance, if any
  • No extra benefit available
Casualty:
  • Two casualty visits per family, limited to R1,300
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • N/A
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 2
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
Extended Fund: RM= R12,250
M1+= R24,350
R R
General info:
  • This plan has an "extra" fund ("day-to-day benefit"), so most out of hospital costs are paid by this, subject to sub-limits per benefit (see below)
  • 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: R1,398 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 R2,903 per person and R5,590 per family, subject to day-to-day benefit
  • No extra benefit available
Pathology:
  • Paid by Bestmed if network is used, subject to protocols and day-to-day benefit
  • No extra benefit available
General radiology:
  • Paid by Bestmed if network is used, subject to protocols and day-to-day benefit
  • No extra benefit available
Specialised radiology:
  • Bestmed pays for 3 MRI/CT scans and 1 PET scan per person
  • All else is paid by you out-of-pocket
  • No extra benefit available
Supplementary Services: (Physio, etc)
  • R3,870 per person and R7,686 per family
  • From day-to-day benefit
  • No extra benefit available
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MATERNITY BENEFITS:
Pulse 2
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 2
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Oncology programme
  • Biological medicine: R141,900 per person
  • 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 cover limit). This includes extra cover for biological medicine short-payments or co-payments. More info
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DENTISTRY:
Pulse 2
Scheme Benefits Gap benefits
Standard Dentistry:
  • Standard dentistry: R6,611 per person and R8,385 per family, paid from day-to-day benefit
  • Benefit shared with specialised dentistry
Specialised Dentistry:
  • Specialised dentistry: R6,611 per person and R8,385 per family, paid from day-to-day benefit
  • Benefit shared with standard dentistry
  • 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: 100% scheme rate
Orthodontics: See above
Maxillo Facial Surgery:
  • Up to 100% scheme rate
  • 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 2
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
  • An additional 16 non-CDL conditions are covered at 85% scheme rate, with an overall limit of R6,235 per person and R12,470 per family
  • If you voluntarily use medicine that is not on Bestmed's list ("formulary"), you pay a 25% co-payment
  • No extra benefit available
Acute (presrcibed) medication:
  • R4,139 per person and R8,385 per family
  • Paid by Bestmed only if on medicine list ("provider network formulary")
  • From day-to-day benefit
  • No extra benefit available
Over-the-counter:
  • R550 per family
  • No extra benefit available
Birth Control:
  • R2,097 per family per year, paid by Bestmed
  • No extra benefit available
On Discharge:
  • 7 days
  • No extra benefit available
Biological:
  • R141,900 per person
  • 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 cover limit). This includes extra cover for biological medicine short-payments or co-payments. More info
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OPTOMETRY:
Pulse 2
Scheme Benefits Gap benefits
Optometry:
Limit:Paid by scheme, every 24 months
Consult:1 per person
Frames:R825
Single lenses100% cost
Bifocals:R175
MultifocalsR710
ContactsR1,435
Refractive Surgery:R8,546
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 2
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 or R29,240 per person
  • 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 R2,700 per person and R5,200 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 2
Scheme Benefits Gap benefits
General Appliances:
  • Out of hospital, R9,353 per family from day-to-day benefit
  • In-hospital, 100% scheme rate
  • No benefit
1.1. Hearing Aids:
  • R26,015 per family, every 2 years
  • No benefit
1.2. Wheelchairs:
  • R12,040 per family every 4 years
  • No benefit
Dialysis:
  • Up to 100% scheme rate
  • Gap cover will pay shortfall for authorised in and out-of-hospital treatment
  • Note that gap does not pay penalties, for example if you have a co-payment because you voluntarily opted to use a non-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:
  • Wound care: R9,030 per family
  • No extra benefit available
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WELLNESS/PREVENTATIVE BENEFITS:
Pulse 2
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:
  • No benefit
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PROSTHETICS:
Pulse 2
Scheme Benefits Gap benefits
Overal Limit:
  • Internal: R96,213 per family
  • External: R23,220 per family
  • 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): R15,964
  • Vascular: R37,195
  • Pacemaker, dual chamber: R50,418
  • Spinal: R37,195
  • Artificial disk: R16,340
  • Drug-eluting stents: R16,340
  • Mesh: R16,340
  • Gynaecology/Urology: R12,148
  • Lens implants: R10,428 per lens
  • Hip replacement and other major joints: R44,505
  • Knee prosthesis: R51,976
  • Minor joints: R19,350
  • 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