Bestmed Pulse 2 medical aid plan: 2017

Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB. Pay for maximum 4 children.

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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Hospital Choice:
  • Network or R10,000 co-payment
Specialised Radiology:
Supplementary Services: (Physio, etc)
Transplants:
Co-payments: None
Alternatives to hospitals:

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • GP Network: unlimited GP consults
  • Out-of-network: R1,200 per family, limited to two consults
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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Specialists consultations:
  • M= R2,350 and M1+ =R4,800
  • Paid from day-to-day benefit
Pathology:
  • Cover from network, subject to protocols and day-to-day benefit
General radiology:
  • Cover from network, subject to protocols and day-to-day benefit
Specialised radiology:
  • Maximum 3 MRI/CT scans and 1 PET scan per person
Supplementary Services: (Physio, etc)
  • M= R3,350 and M1+ =R6,600
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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Consultations:
  • 12 consults, paid by scheme
Scans:
  • 2 scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • Subject to approved treatment plan
  • Biological medicine: R122,000 per person

Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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DENTISTRY:
Dentistry:
  • R5,700 per person and R7,250 per family
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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Orthodontics: See above
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 16 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit:R5,450 per person and R10,800 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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Acute (presrcibed) medication:
  • M =R3,600 and M1+ =R7,200
  • Paid from day-to-day benefit
Over-the-counter:
  • R525 per family
Birth Control:
  • R1,800 per family per year, paid by scheme
On Discharge:
  • 7 days
Notes:

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OPTOMETRY:
Optometry:
  • Consultation: R350
  • Frame: R550
  • Lenses: Single R165 or Bifocal R360 or Multifocal R660
  • Contact lenses: R1,210
  • Refractive surgery: R7,350 per eye
  • Paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • 21 days per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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Out-of-hospital:
  • M= R2,350 and M1+ =R4,800
  • Shared with specialist benefit
  • Paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • R8,100 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

Compare with these plans:

1.1. Hearing Aids:
  • R22,450 per family, every 2 years
1.2. Wheelchairs:
  • R10,400 per family, every 4 years
Dialysis:
HIV:
  • Managed care programme
Emergency Transport: ER24
International Coverage:
Other:
  • R7,750 per family

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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Pneumonia vaccines:
  • Covered
Back Rehabilitation Programme:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear: No benefit
Mammogram: No benefit
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

Compare with these plans:
Sub-limits:

    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