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Clone of Pulse 1: R0 - R5 500

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Type of Medical Aid Plan: 
Capitation
Medical Aid Year: 
2021
Income Level: 
R0 - R5 500
Day to day Benefits: 

Unlimited cover for GP consultations at a Bestmed Pulse 1 Network GP. Referral from the network GP through Bestmed Pulse 1 network providers for medication, specialist consultations, basic blood tests and X-rays. Basic optometry and dental consultations for fillings and tooth extractions, through Pulse network providers

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited at 100% of Bestmed Tariff (BT)
Hospitals: 

Bestmed Pulse Network Hospital and a Designated Service Provider(DSP) specialist on the Pulse network

Upfront Payments to hospitals: 

If you use a hospital outside of the Pulse Hospital Network, there will be an upfront payment of R11 874

Casualty / Emergency Visits: 
Casualty and out-of-network GP visits are limited to R1 425 per family per year
Specialists: 
100% of BT. DSP specialist network applicable
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of BT. DSP specialist network applicable
Radiology and pathology: 
100% of BT
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Co-payment of R3 800 on laparoscopic and endoscopic procedures that are clinically approved
MRI and CT scans: 
100% of BT. Subject to pre-authorisation
ICU and High Care: 
100% of BT
Dialysis: 
PMBs only at DSPs
Organ Transplants: 
100% of BT. Only PMBs
Oncology / Cancer: 
PMBs only at DSPs
Neck and Back Operations: 
Subject to the outcome of referral, assessment and rehabilitation treatment at a Bestmed Document Based Care (DBC) back and neck treatment programme
Joint Replacements: 
PMBs only at DSPs and subject to prosthesis limits
Prosthesis: 

100% of BT. Subject to preferred providers and prosthesis limit of R53 079 per family. Internal: Sub-limits per beneficiary: Functional limited to R11 281; Vascular R26 302; Pacemaker (dual chamber) R42 986; Endovascular and catheter-based procedures - no benefit; Spinal R26 302; Artificial disc - no benefit; Drug-eluting stents - PMBs and DSP products only; Mesh R9 619; Gynaecology/Urology R7 944; Lens implants R5 523 per lens, per eye. PMB prosthesis limits: Hip replacement and other major joints R26 956; knee replacement R34 080; minor joints R12 765. External: No benefit except for PMBs

Medical and Surgical Appliances: 
In hospital; 100% of BT. Limited to R6 531 per family. Out of hospital; no benefit
Maternity Confinements: 
100% of BT
In Hospital Dentistry: 
No benefit
Take home Medicine: 
100% of BT. Limited to 3 days supply
Rehabilitation, Hospice and Step-down facilities: 
No benefit for rehabilitation after trauma. Chemical and substance abuse-PMBs only and subject to network facilities. 100% of BT. Limited to 21 days per beneficiary
Treatment for Mental Health: 
100% of BT. Limited to 21 days per beneficiary
HIV / AIDS: 
PMBs only at DSPs
Ambulance Service: 
ER 24 for emergencies
International Travel Benefit: 
Up to R10 million and a maximum of 90 days. Services rendered by Bryte Insurance and managed by ER24
Day-to-day benefits
GP consultations: 

Unlimited cover for GP consultations at a Bestmed Pulse 1 Network GP

Specialist consultations: 

Subject to referral by a Pulse 1 Network GP and Pulse Specialist DSP network. Limited to M = R1 187, M1+ = R1 782

Acute medicine: 

100% of BT. Subject to Bestmed formulary

Over-the-counter (OTC) Medicine: 

Limited to R387 per family

Optometry benefits: 
Subject to services rendered by a PPN provider per 24 month cycle. Consultation, frame and 100% of cost for standard lenses R880 or contact lenses limited R630
Basic dentistry: 
Subject to Bestmed Pulse Dental Network
Specialised Dentistry: 
No benefit
Orthodontics: 

No benefit

MRI and CT Scans (Out of Hospital): 
No benefit
Radiology and Pathology: 
Subject to Provider network and referral by Pulse 1 Network Provider. Pulse 1 protocols and tariff lists apply
Pregnancy benefits: 
100% of BT. Subject to registration on the Maternity Care programme after 12 weeks; 9 antenatal and 1 post-natal consult at a GP or gynaecologist or midwife and 2x 2D scans. Antenatal iron and folic acid supplements x 9 fills maximum R100 per claim
Physiotherapy and Occupational Therapy day to day: 
No benefit
Chronic Conditions
Provider: 
Bestmed pharmacy network
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to approval

Additional Chronic Conditions: 
No benefit
Preventative Care Benefits
Preventative Benefits: 

Flu and pneumonia vaccines; paediatric immunisation; female contraceptives R2 315 pbpa; back and neck preventative programme; HPV vaccines for females 9-26 years. Tempo programme has Individual Health Risk Assessments for adults aged 18 and older and age specific assessments for child dependants aged 0 - 17 years; family nutrition assessment and fitness and nutritional interventions for beneficiaries aged 18 and older

Total Contributions
Total Contribution Main Member: 
1694.00
Total Contribution Adult: 
1610.00
Total Contribution Child*: 
1019.00
Pulse 1: R0 - R5 500
Risk Contributions
Risk Contribution Main Member: 
1694.00
Risk Contribution Adult: 
1610.00
Risk Contribution Child: 
1019.00
Medical Aid Plan Name Term: 
Pulse 1 R0-R5500