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Pulse1

Plan Details

Hospital & Emergencies

Accommodation (hospital stay) and theatre fees

100% Scheme tariff at a designated service provider (DSP) hospital.

Take-home medicine

100% Scheme tariff.  Limited to 3 days’ medicine

Biological medicine during hospitalisation

Limited to R15 000 per family per annum.  Subject to pre-authorisation and funding guidelines.

Treatment in mental health clinics

100% Scheme tariff.  Limited to 21 days per beneficiary.

Treatment of chemical and substance abuse

100% Scheme tariff (only PMBs). .  Limited to 21 days per beneficiary subject to network facilities.

Consultations and procedures

100% Scheme tariff.

Surgical procedures and anaesthetics

100% Scheme tariff.
Excluded from benefits: functional nasal surgery, surgery for medical conditions, e.g. Epilepsy, Parkinson’s disease, etc., and procedures where stimulators are used.

Organ transplants

100% Scheme tariff. (PMBs only)

Major medical maxillo-facial surgery strictly related to certain conditions

No benefit.
 

 

Dental and oral surgery (In- or out of hospital)

No benefit

Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)

100% Scheme tariff.  Limited to R55 309 per family.

Prosthesis – Internal Note: Sub-limit subject to the overall annual prosthesis limit. *Functional: Item utilised towards treating or supporting a bodily function.

Sub-limits per beneficiary:
*Functional R11 755   Vascular R27 406   Pacemaker (dual chamber) R44 791   Endovascular and catheter-based procedures - no benefit   Spinal R27 406   Artificial disc - no benefit   Drug-eluting stents - PMBs and DSP products only   Mesh R10 023   Gynaecology/ Urology R8 278   Lens implants R5 755 a lens per eye

Prosthesis – External

No benefit (PMBs only)

Exclusions Limits and co-payments applicable. Preferred provider network available.

Joint replacement surgery (except for PMBs). PMBs subject to prosthesis limits:
Hip replacement and other major joints R28 088.   Knee replacement R35 512.   Minor joints R13 301

Orthopaedic and medical appliances

100% Scheme tariff Limited to R6 806 per family.

Pathology

100% Scheme tariff.

Basic Radiology

100% Scheme tariff

Specialised diagnostic imaging (Including MRI scans, CT scans, isotope studies)

100% Scheme tariff Subject to pre-authorisation.

Confinements (Birthing)

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Oncology

Oncology programme. 100% of Scheme tariff. DSP applies. Subject to pre-authorisation.

Peritoneal dialysis and haemodialysis

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Refractive surgery and all types of procedures to improve or stabilise vision (except cataracts)

No benefit (PMBs only).

HIV/AIDS

100% Scheme tariff Subject to pre-authorisation and DSPs.

Midwife-assisted births

100% Scheme tariff. Protocols apply

Supplementary services

100% Scheme tariff.

Alternatives to hospitalisation

100% Scheme tariff.

Palliative care and Home-based care in lieu of hospitalisation

100% Scheme tariff, limited to R60 000 per beneficiary per annum. Subject to available benefit, pre-authorisation and treatment plan.

Day procedures at a day-hospital facility

Day procedures at a day-hospital facility funded at 100% Scheme tariff Subject to pre-authorisation. DSPs apply for PMBs

International travel cover

Leisure Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 90 days, with R5 million for one member and R10 million for principal member and dependants.
Business Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 45 days, with R5 million for one member and R10 million for principal member and dependants.

Co-payments

Co-payment of up to R12 373 per event for voluntary use of a non-DSP hospital.

Day-to-Day

Medical Savings

Basic and Specialised Dentistry

Where clinically appropriate and subject to Bestmed Pulse1 protocols. Includes consultations, primary extractions, fillings, fluoride treatment, scaling and polishing. Limited to 2 consultations for a full mouth examination per beneficiary per year. Bestmed Pulse1 dental network providers and Bestmed Pulse1 list of approved dental codes. Dentures limited to a maximum of 2 removable acrylic dentures (i.e. 2 single denture plates) per family every 24 months. Co-payment of 20% of total fee which the member must pay directly to the provider.

Optometry Services

Benefits available every 24 months from date of service at PPN provider only.

  • Consultation - only PPN providers
  • Frame = R225 covered AND Standard lenses
  • Single vision lenses = R210 OR 
  • Bifocal lenses = R445
  • In lieu of glasses members can opt for contact lenses, limited to R630

Over-the-counter medicine

Pathology

100% Scheme tariff. Basic blood tests as requested by a Bestmed Pulse1 Network FP and subject to Bestmed Pulse1 Network protocols and approved pathology list of codes.

Medicines

CDL and PMB chronic medicine

100% Scheme tariff.
30% co-payment on non-formulary medicine at a preferred provider network pharmacy.

Non-CDL chronic medicine

No benefit.

Biologicals and other high-cost medicine 

PMBs only - subject to pre-authorisation.

Acute medicine 

100% Scheme tariff.
Subject to Bestmed formulary only.

Over-the-counter (OTC) medicine 

Limited to R600 per family.
Subject to preferred provider network pharmacy. Includes sunscreen, vitamins and minerals with NAPPI codes on Scheme formulary.

Maternity benefits

100% Scheme tariff. Subject to the following benefits

Consultations: 
  • 9 antenatal consultations at a Family Practitioner OR gynaecologist OR midwife
  • 1 lactation consultation with a registered nurse or lactation specialist.
Ultrasounds:
  • 1 x 2D ultrasound scan at 1st trimester (between 10 to 12 weeks) at a Family Practitioner OR gynaecologist OR radiologist
  • 1 x 2D ultrasound scan at 2nd trimester (between 20 to 24 weeks) at a Family Practitioner OR gynaecologist OR radiologist
Supplements:
  • Any item categorised as a maternity supplement can be claimed up to a maximum of R120 per claim, once a month, for a maximum of 9 months.

Preventative care benefits

Flu vaccines
  • All ages
  • 1 per beneficiary per year
  • Flu vaccine via Bestmed Network Pharmacy or FP
Pneumonia vaccines
  • Children <2 years
  • High-risk adult group

        Children:

  • As per schedule of Department of Health

        Adults:

  • Twice in a lifetime with booster above 65 years of age

       Adults:

  • Bestmed will identify certain high-risk individuals who will be advised by the Scheme to be immunised
Travel vaccines
  • All ages
  • Quantity and frequency depending on product up to to the maximum allowed amount
  • Mandatory travel vaccines for typhoid, yellow fever, tetanus, meningitis, hepatitis and cholera from Scheme risk benefits
Female contraceptives
  • All females of child-bearing age
  • Quantity and frequency depending on product up to the maximum allowed amount. Mirena device - 1 device every 60 months
  • Limited to R2 412 per beneficiary per year. Includes all items classified in the category of female contraceptives
Pap smear
  • Females 18 years and older. Once every 24 months.
  • Can be done at a Pulse Specialist DSP gynaecologist, Bestmed Pulse1 Network FP or network pharmacy clinic.
  • Consultation paid from the available consultation benefit.
Baby growth and development assessments
  • 0-2 years.
  • 3 assessments per year.
  • Assessment are done at a Bestmed Network Pharmacy Clinic.
Paediatric immunisation
  • Babies and children
  • Funding for all paediatric vaccines according to the state-recommended programme.
PSA screening
  • Males 50 years and older.
  • Once every 24 months. Can be done at a Pulse Specialist DSP urologist or Bestmed Pulse1 Network FP.
  • Can be done at a urologist, FP or network pharmacy clinic. Consultation paid from the available consultation benefits
Back and neck preventative programme
  • All ages
  • Subject to pre-authorisation
  • Preferred providers (DBC/Workability Clinics)
  • This is a preventative programme with the objective of preventing back and neck surgery. The Scheme may identify appropriate participants.
  • Based on the first assessment, a rehabilitation treatment plan is drawn up and initiated over an uninterrupted period that will be specified by the provider.
  • Use of this programme is in lieu of surgery
Mammogram  (tariff code 34100)
  • Females 40 years and older
  • Once every 24 months
  • Must be referred by Family Practitioner (FP) or Pulse Specialist DSP

From R 2537 per month*

Add Dependants

Adults
0
Children
0

*Depending on your income bracket, you may be eligible for a reduced premium. Please ask a sales consultant for more information

Our network options offer you unlimited in-hospital cover with either limited essential day-to-today benefits, or comprehensive savings for your consultations with designated healthcare providers.

You pay for a maximum of three children. Any additional children can join as beneficiaries of the Scheme at no additional cost.

Contributions (income bracket R0 - R5 500)
Member: R1 760
Adult dependant: R1 673
Child dependant: R1 059
Maximum child dependants: 3

Contributions (income bracket R5 501 - R8 500)
Member: R2 114
Adult dependant: R2 009
Child dependant: R1 269
Maximum child dependants: 3

Contributions (income bracket >R8 501)
Member: R2 537
Adult dependant: R2 284
Child dependant: R1 269
Maximum child dependants: 3

Child dependants under the age of 24 years and registered students up to the age of 26 years, in accordance with the Rules, are regarded as child dependants.

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