Bestmed Pulse 1A medical aid plan: 2020

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Pulse 1 A
2020 Costs:
Total Cost pm:

Main member:

R1,626

Adult:

R1,545

Child:

R978
Savings (per year):
  • No savings option on this plan
Income band:



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IN HOSPITAL PROCEDURES:
Pulse 1 A
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • The Blue Plan gap cover will increase this to 500% scheme rate
network Specialists:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
non-Network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Hospital Choice:
  • Choose from Network hospitals
Penalty for using other hospital:
  • n/a
Specialised Radiology:
  • 100% scheme rate
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
Co-payments:
    You or your gap cover pay R3,619 co-payment for:
  • Laparoscopic procedures
  • Prostate procedures
  • Procedures for prolapse/incontinence
  • Arthroscopy, other than acute trauma
  • Endoscopy investigations done primarily in hospital
Alternatives to hospitals:
  • Bestmed pays up to 100% scheme rate
Casualty:
  • R1,357 per family, shared with out-of-network GP visits
  • Both the Blue Plan and Red Plan gap cover will pay up to R20,000 per person for unpaid casualty costs in event of emergency
Other:
    Bestmed does not pay for:
  • Functional nasal surgery
  • Surgery for medical conditions e.g epilepsy, Parkinson's etc
  • Procedures where stimulators are used
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R157,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R157,000 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 A
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • Network Pulse1 GPs: unlimited
  • Not-contracted GPs: R1,357 per family, shared with casualty benefit
Childcare:
  • No extra benefits
Specialists consultations:
  • Must be referred and from Pulse Specialist DSP network
  • R500 co-payment for non-DSP use in case of PMBs
  • M =R1,131 and M+ =R1,697
Pathology:
  • Must use Provider network and referral from Pulse1 network provider
General radiology:
  • Must use Provider network and referral from Pulse1 network provider
Specialised radiology:
  • No benefit, unless PMB
  • No extra benefit available
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB



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MATERNITY BENEFITS:
Pulse 1 A
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
    Paid by Bestmed:
  • 9 consults, at GP/gynae/midwife
  • Iron and folic acid supplements
  • Post natal consult with GP/gynae/midwife
Scans:
    Bestmed pays for:
  • 2 x 2D scans



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CANCER (ONCOLOGY):
Pulse 1 A
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • PMBs only, at DSP (designated service provider)



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DENTISTRY:
Pulse 1 A
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Subject to network provider and protocols
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Specialised Dentistry:
  • No benefit
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



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MEDICATION:
Pulse 1 A
Scheme Benefits: Notes and Links:
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 medicine that is not on Bestmed's list ("formulary"), you pay a 40% co-payment
Acute (presrcibed) medication:
  • Paid by Bestmed if on medicine list ("provider network formulary")
Over-the-counter:
  • R368 per family
Birth Control:
  • R2,205 per family per year, paid by Bestmed
On Discharge:
  • 3 days
Biological:
  • No benefit, unless PMB level of care



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OPTOMETRY:
Pulse 1 A
Scheme Benefits: Notes and Links:
Optometry:
Limit:Paid by scheme, every 24 months
Consult:1 per person
Frames:R237
Single lenses100% cost
Bifocals:100% cost
Multifocals100% cost
ContactsR600
Refractive Surgery:no benefit
Notes:Above benefits from network provider



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MENTAL HEALTH:
Pulse 1 A
Scheme Benefits Notes and Links:
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, 21 days per person
Out-of-hospital:
  • PMBs always paid in full at DSP, and include consultations
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



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OTHER BENEFITS:
Pulse 1 A
Scheme Benefits Notes and Links:
General Appliances:
  • Out of hospital: No benefit
  • In-hospital, 100% scheme rate up to R6,220 per family
1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
  • PMB only
International Insurance:
    In brief (all subject to conditions of policy):
  • Medical expenses up to R10 million and maximum 90 days
Other:
  • No benefit



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WELLNESS/PREVENTATIVE BENEFITS:
Pulse 1 A
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • No benefit
Pap Smear:
  • No benefit, unless PMB
Mammogram:
  • No benefit, unless PMB
PAS Test:
  • No benefit, unless PMB
HIV Test:
Other:
  • HPV Vaccinations
  • Tempo Programme which includes bio screening, child assessments, nutrition assessments, fitness and nutritional interventions (biokineticist and dietician consults)



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PROSTHETICS:
Pulse 1 A
Scheme Benefits: Notes and Links:
Overal Limit:
  • Overall: R50,552 per family
  • External: no benefit
Sub-limits:
    (per person):
  • Functional (treating or supporting a bodily function): R10,744
  • Vascular: R25,049
  • Pacemaker, dual chamber: R40,939
  • Spinal: R25,049
  • Mesh: R9,161
  • Gynaecology/Urology: R7,566
  • Lens implants: R5,260 per lens
    Exclusions:
  • Endovascular and catheter-based procedures
  • Artificial disk
  • Drug eluting stents (PMBs only)
  • Joint replacements, unless PMB
    PMB joint replacements - prothesis limits:
  • Hip replacement and other major joints: R25,672
  • Knee replacement: R32,457
  • Minor Joints: R12,157



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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