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Pulse 2

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Type of Medical Aid Plan: 
Traditional
Medical Aid Year: 
2020
Day to day Benefits: 

Overall day-to-day limit of M = R13 854; M1+ = R27 537

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 309

Casualty / Emergency Visits: 
Casualty and out-of-network GP visits are limited to R1 471 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): 
100% of BT
MRI and CT scans: 
100% of BT. Subject to pre-authorisation
ICU and High Care: 
100% of BT
Dialysis: 
100% of BT. Only at DSPs
Organ Transplants: 
100% of BT. Only PMBs
Oncology / Cancer: 
Oncology programme at 100% of BT
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: 
Subject to DSPs and prosthesis limits
Prosthesis: 

100% of BT. Subject to preferred providers and prosthesis limit of R101 216 per family.
Internal: Sub-limits per beneficiary: Functional limited to R16 794; Vascular R39 129; Pacemaker (dual chamber) R53 040; Spinal R39 129; Artificial disc R17 190; Drug-eluting stents R17 190; Mesh R17 190; Gynaecology/Urology R12 780; Lens implants R10 970 per lens, per eye; Hip replacement and other major joints R46 819; knee replacement R54 679; minor joints R20 356.
External: limited to R24 427 per family

Medical and Surgical Appliances: 
In hospital; 100% of BT. Out of hospital. limited to R9 839 per family. Wheelchairs limited to R12 666 pf. Hearing aids limited to R27 368 and subject to pre-authorisation, quotation, audiogram and motivation
Maternity Confinements: 
100% of BT
In Hospital Dentistry: 
100% of BT for dental and oral surgery and maxillofacial surgery
Take home Medicine: 
100% of BT. Limited to 7 days supply
Rehabilitation, Hospice and Step-down facilities: 
No benefit for rehabilitation after trauma. Chemical and substance abuse are subject to network facilities and limited to 21 days or R30 760 per beneficiary
Treatment for Mental Health: 
100% of BT. Limited to 21 days per beneficiary
HIV / AIDS: 
100% of BT. Subject to pre-authorisation and 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 GP consultations at Bestmed GP network providers

Specialist consultations: 

Subject to overall day-to-day limit, Pulse specialist network and referred by Bestmed GP network provider. Limited to M = R3 054, M1+ = R5 881.

Acute medicine: 

Subject to overall day-to-day limit. 100% of BT, limited to M = R4 354, M1+ = R8 821

Over-the-counter (OTC) Medicine: 

Limited to R579 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 or contact lenses = R1 510
Basic dentistry: 
Subject to overall day-to-day limit. Limited to M = R6 955, M1+ = R8 821
Specialised Dentistry: 
Subject to overall day-to-day limit and pre-authorisation. Limited to M = R6 955, M1+ = R8 821
Orthodontics: 

Subject to overall day-to-day limit and pre-authorisation. Limited to M = R6 955, M1+ = R8 821

MRI and CT Scans (Out of Hospital): 
Subject to pre-authorisation. Maximum of 3 scans per beneficiary. PET scan: 1 per beneficiary
Radiology and Pathology: 
Subject to overall day-to-day limit, pre-authorisation and referral by a network provider. Network provider 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
Physiotherapy and Occupational Therapy day to day: 
Subject to overall day-to-day limit. Limited to M = R4 071, M1+ = R8 086
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: 
16 conditions. 90% of BT and limited to M = R6 559; M1+ = R13 118. Biological and other high-cost medicine limited to R149 279
Preventative Care Benefits
Preventative Benefits: 

Flu and pneumonia vaccines; paediatric immunisation; female contraceptives R2 205 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: 
5770.00
Total Contribution Adult: 
5770.00
Total Contribution Child*: 
1371.00
Pulse 2
Risk Contributions
Risk Contribution Main Member: 
5770.00
Risk Contribution Adult: 
5770.00
Risk Contribution Child: 
1371.00
Medical Aid Plan Name Term: 
Pulse 2