Bestmed Pulse 1 Options

On the Bestmed Pulse 1 option in-hospital services are paid from Scheme risk benefit. The Pulse 1 network covers most out-of-hospital services, however, members will still be required to go to a DSP. Some preventative care services are available from Scheme risk benefit. (Emergency out-of-network visits with FPs must be paid by members upfront and then claimed back from the available out-of-network benefit with Bestmed).

Bestmed Pulse 1 members must make use of the Pulse specialist DSP network.

Please familiarise yourself with the Designated Service Providers (DSPs) and networks for this option. This includes Pulse DSP specialists and DSP hospitals. Hospital costs will be covered unlimited at the Scheme negotiated tariff at the Bestmed hospital network as listed on the website, subject to pre-authorisation.

The DSP hospital network consists of all Netcare hospitals in South Africa. In areas where there are no Netcare hospitals, other hospitals are contracted as DSPs.

Please refer to the Bestmed website on www.bestmed.co.za for a list of the DSP hospitals.

Process for hospital authorisation

• All members on the Pulse 1 option must make use of the Bestmed Pulse 1 family practitioners (FPs).
• The Bestmed Pulse 1 FP will refer the member to a Bestmed Pulse DSP specialist should a specialist consultation be required.
• Should the Bestmed Pulse DSP specialist indicate that hospitalisation is required, the member needs to contact Bestmed on 080 022 0106 for pre-authorisation. Bestmed will only authorise admissions to contracted DSP hospitals.

Emergency admittance in a non-DSP hospital

• Should a member be admitted for an emergency condition in a non-DSP hospital, Bestmed will require the patient to be stabilised in that non-DSP hospital
• As soon as the patient is stabilised, he/she will be transferred to the closest DSP hospital by ER24
• All benefits below may be subject to pre-authorisation and clinical protocols and designated hospital networks
• Co-payments up to a maximum of R10 000 per event for voluntary use of a non-DSP hospital will be charged

Medical Event	Scheme Benefit
Accommodation (hospital stay) and theatre fees	100% Scheme tariff at a Netcare DSP hospital
Take-home medicine	100% Scheme tariff Limited to 3 days’ medicine
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 (Only PMBs)
Major medical maxillo-facial surgery strictly related to certain conditions	No benefit
Dental and oral surgery	No benefit
Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)	100% Scheme tariff. Limited to R44 700 per family
Prosthesis – Internal Note: Sub-limit subject to the prosthesis limit	Sub-limits per beneficiary: *Functional limited to R9 500 Vascular: R22 150 Pacemaker (dual chamber): R36 200 Endovascular and catheter-based procedures – no benefit Spinal R22 100 Artificial disk – no benefit Drug-eluting stents – no benefit Mesh: R8 100 Gynaecology/Urology: R6 690 Lens implants: R4 650 per lense
Prosthesis – External	No benefit
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: R22 700 Knee replacement: R28 700 Minor joints: R10 750
Orthopaedic and medical appliances	100% Scheme tariff Limited to R5 500 per family
Pathology	100% Scheme tariff
Diagnostic imaging	100% Scheme tariff
Specialised diagnostic imaging	100% Scheme tariff
Oncology	PMBs only at DSP state facilities where available
Peritoneal dialysis and haemodialysis	PMBs only at DSPs
Confinements	100% Scheme tariff
Refractive surgery	No benefit
Midwife-assisted births	100% Scheme tariff
Supplementary services	100% Scheme tariff
Alternatives to hospitalisation	100% Scheme tariff
Emergency Evacuation	100% Scheme tariff. Pre-authorised and rendered by ER24
Co-payments	Co-payment where procedure has been clinically approved: R3 200 on all laparoscopic procedures R3 200 on prostate procedures R3 200 on procedures for prolapse/incontinence R3 200 on arthroscopy other than acute trauma R3 200 on endoscopy investigations done primarily in hospital

Out-of-hospital benefits are paid at 100% of the Bestmed Pulse 1 tariff and are subject to the Bestmed Pulse 1 tariff protocols, unless otherwise stated.

Note: Granting of benefits under the primary care services and the Scheme benefits, shall be subject to treatment protocols, preferred providers, DSPs, dental procedure codes, pathology and radiology lists of codes and medicine formularies as accepted by the Scheme.

What are the benefits covered by the tariff for the Bestmed Pulse 1 Family Practitioners (FPs)?

• As many consultations as are medically necessary to get you healthy
• Selected minor trauma treatment, such as stitching of wounds
• Medicine for acute ailments, subject to the Bestmed Pulse 1 formulary

You will be responsible for the payment of any services outside of the Bestmed Pulse 1 protocols.

FP Consultations Benefit Description

• Bestmed Pulse 1 agreed tariff
• Unlimited medically necessary consultations with a Bestmed Pulse Network FP for basic primary care
• Pre- and postnatal care:
  • Supervision of uncomplicated pregnancy up to week 20
  • Includes two 2D sonar scans per pregnancy during the 1st and 2nd trimesters
• Specified minor trauma treatment including: stitching of wounds, draining of absyss, removal of foreign body, limb cast

What happens if I need a FP after hours or while on holiday?

The Pulse 1 benefit makes provision for after-hours emergency visits outside of the network.

You will be required to pay for all treatment received at the point of service. The costs of these services may be claimed back from Bestmed by completing a reimbursement form which can be downloaded from Bestmed’s website or obtained from Bestmed. The reimbursement will be subject to Bestmed Pulse 1 protocols.

Refunds are subject to Bestmed Pulse 1 protocols

Out-of-network & Casualty Visits Benefit Description

• Out-of-network visits to a FP are limited to a maximum of R1 200 per family per year.
• Any radiology and pathology treatment received as a result of the casualty visit will be paid from the R1 200 out-of-network visit limit. Once limit has been reached, the costs will be for the member’s own account.
• Excludes services provided by FPs who are not registered with the Health Professionals Council of South Africa (HPCSA).
• Emergency visits are unlimited at any State facility.

Acute Medicine

• Reference pricing is applied. If a product is prescribed that is more expensive than the reference price, the patient will need to pay the difference in price at the point of dispensing.
• Quantity limits apply to some items on this formulary. Quantities in excess of this limit will need to be funded by the member at the point of dispensing, unless an authorisation has been obtained for a greater quantity.
• Other generic products not specifically listed will be reimbursed in full if the price falls within the reference price range for that group.
• The formulary is subject to regular review. Bestmed reserves the right to update and change the formulary when new information becomes available, prices change or when new medicines are released.
• While every effort has been made to ensure that products listed are available on the market, it is possible that some products may be discontinued by the manufacturers during the course of the year.

Acute Medicine Benefit Description

• Bestmed agreed tariff.
• Unlimited acute medicine as dispensed or prescribed by a Bestmed Pulse 1 Network FP and dispensed at a preferred network pharmacy.
• Subject to reference pricing and the Bestmed Pulse 1 acute medicine formulary.

Chronic Medicine

Chronic application forms must accompany all first-time applications. All applications MUST include valid ICD 10 codes.

If the prescriber or patient insists on a non-formulary product, where a generic equivalent is available on the formulary, a co-payment will be levied at the point of dispensing.

Reference pricing is applied. If a product is prescribed that is more expensive than the reference price, the patient will need to pay the difference in price at the point of dispensing.

Other generic products not specifically listed will be reimbursed in full if the price falls within the reference price range for that group.

A clinically relevant motivation is required when prescribing any product which does not appear on this list.

What if I have a chronic condition?

• Please consult your Bestmed Pulse 1 Network FP to confirm your diagnosis.
• Once confirmed, the Bestmed Pulse 1 Network FP will complete a chronic application form to register you for chronic medicine benefits.
• This form will be forwarded to Bestmed by your FP for evaluation.
• You will be notified via SMS as soon as the chronic application has been processed.
• Approval of chronic medicine benefits is subject to the clinical protocols for the chronic conditions covered by Bestmed and a chronic medicine formulary.
• Should you have any enquiries in this regard, please contact the Bestmed Contact Centre on 086 000 2378.
• Note that most chronic medicines may only be collected once per month.
• It will be necessary for you to visit your Bestmed Pulse 1 FP to renew your chronic repeat script every six months. If there is a change in medication or condition, a new application will need to be submitted.
• This script should be submitted to Bestmed for your chronic medicines authorisation to be updated.

Chronic Medicine Benefit Description

• 100% contracted tariff and preferred network pharmacies
• Chronic medicine for CDL and PMB conditions only
• Unlimited chronic medicine subject to registration and approval from Bestmed and according to the Bestmed chronic medicine formulary only
• Chronic medicine prescribed by a specialist out-of-hospital will only be covered on registration and if approved by Bestmed according to the Bestmed chronic medicine formulary

What is over-the-counter (OTC) medicine?

Over-the-counter (OTC) medicine is available for self-diagnosis and treatment, for example, if you have a cold and you need to buy medicine without seeing your Bestmed Pulse 1 FP.

There is a R350 limit which is subject to Bestmed Pulse 1 OTC medication formulary and medication being obtained at a preferred network pharmacy.

What are my dental benefits?

Dental benefits are obtainable from a Bestmed Pulse 1 network dentist.

The dental benefits are for basic dentistry only and are subject to clinical protocols and an approved tariff list.

Benefits are limited to primary extractions, fillings, scaling and polishing as well as emergency pain relief.

Dentures: Limited to a maximum of two removeable acrylic dentures (i.e. two single denture plates) per family every 24 months. There is a co-payment of 20% of the total fees which the member must pay directly to the dentist.

Crowns and other specialised dentistry are not covered.

Please contact your medical aid scheme to confirm which benefits are covered.

Basic Dentistry Benefit Description

• When clinically appropriate and subject to Bestmed Pulse 1 protocols; includes consultations, primary extractions, fillings, scaling and polishing.
• Limited to Bestmed Pulse 1 dental network accredited providers and Bestmed Pulse 1 list of approved dental codes.
• Two consultations for a full mouth examination per beneficiary per year subject to Bestmed Pulse 1 list of dental codes.
• Preventative treatments cover scale and polish as well as fluoride treatment.

Dentures Benefit Description

• Limited to a maximum of 2 removable acrylic dentures (i.e. 2 single denture plates) per family every 24 months.
• Covers beneficiaries over the age of 21 years.
• Co-payment of 20% of total fee at practice.
• At Bestmed Pulse 1 network dental provider and accredited dental laboratories and in accordance with the Bestmed Pulse 1 list of approved codes only.

What cover do I have for optometry?

To qualify for the optical benefits, you need to consult a PPN network optometrist

The Pulse 1 benefit covers an optical test, a basic frame from a selected range of frames, with white standard mono- or bifocal lenses; or contact lenses to the value of R555. If you choose a frame outside of the selected range of frames, PPN will pay R150 towards this frame. You will have to pay the balance of the frame directly to the optometrist.

Kindly note that any additional services such as accessories, tinting, enhancements, etc. are not covered under this benefit. You will have to pay these services yourself.

The optical benefit is available per beneficiary, every 24 months

Optometry Benefit Description

• Subject to PPN protocols
• One pair of clear single vision or clear bi-focal lenses in a standard frame OR
• Contact lenses to the value of R555 in lieu of spectacles
• A benefit of R150 will be paid towards a frame selected outside of the standard range
• Exclusions:
  • Tinted lenses
  • Accessories and enhancements
  • Acute medicine
  • Contact lense solutions, etc.
• No benefit if a non-network provider is used

What about blood tests (pathology)?

Basic blood tests are only covered if requested by your Bestmed Pulse 1 Network FP according to an approved tariff list

Your Bestmed Pulse 1 Network FP has a list of approved tests and will advise you if the required tests are covered by Bestmed

You will be responsible for payment of pathology tests not covered under the Pulse 1 benefits

Pathology Benefit Description

• Bestmed Pulse 1 agree tariff
• Basic blood tests as requested by a Bestmed Pulse 1 Network FP and subject to Bestmed Pulse 1 Network FP protocols and approved pathology list of codes

What if I need X-rays (radiology)?

The Pulse 1 benefits cover a list of X-rays that may be performed by a radiologist, if referred by your Bestmed Pulse 1 Network FP.

Your Bestmed Pulse 1 Network FP will advise you whether or not the required X-ray is covered.

You will be responsible for payment of X-rays not covered under the Pulse 1 benefits.

Your FP will refer you to the closest radiology practice to have the X-ray performed.

Radiology Benefit Description

• Bestmed agreed tariff
• Basic X-rays as requested by your Bestmed Pulse 1 Network FP and subject to Pulse 1 protocols and approved radiology list of codes

• Benefits mentioned below may be subject to pre-authorisation, formularies, funding guidelines and Mediscor Reference Price (MRP). DSPs may apply.
• Approved CDL and PMB chronic medicine costs will be paid (unlimited) from Scheme risk.

Benefit Description	Scheme Benefit
CDL & PMB chronic medicine	100% Scheme tariff – 40% co-payment on non-formulary medicine at a preferred provider network pharmacy
Non-CDL chronic medicine	No benefit
Biologicals and other high-cost medicine	No benefit
Acute medicine	Subject to Provider Network Formulary 100% Scheme tariff
Over-the-counter (OTC) medicine	Limited to R350 per family Subject to provider network formulary

Benefits below may be subject to pre-authorisation, clinical protocols, preferred providers, designated service providers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP).

Preventative Care Benefit	Gender & Age Group	Quantity & Frequency	Benefit Criteria
Flu Vaccines	All ages	1 per beneficiary per year	At a Bestmed Pulse 1 Network FP or network pharmacy only Subject to Pulse 1 protocols and where clinically necessary
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: The Scheme will identify certain high-risk individuals who will be advised to be immunised
Female Contraceptives	All females of child-bearing age	Quantity and frequency depending on product up to the maximum allows amount. Mirena device – 1 device every 60 months	Limited to R1 950 per family per year. Includes all items classified in the category of female contraceptives
Spinal/Back Treatment Programme (DBC)	All ages	6 weeks, once per year	Applicable to beneficiaries who have serious spinal and/or back problems and may require surgery. The Scheme may identify appropriate participants for evaluation at a DBC clinic. Based on the evaluation done by a DBC clinic, a rehabilitation treatment plan is drawn up and initiated which lasts 6 weeks, consecutively
Paediatric immunisations	Babies and children	Funding for all paediatric vaccines according to the state-recommended programme
BetterMe Wellness Benefits Note: BIometric screening activates the other assessment benefits	Health risk assessment (biometric screening) at contracted pharmacy or on-site at employer Fitness assessment at a contracted BASA biokineticist – 1 per beneficiary per year (ages older than 13 years) Nutritional assessment – 1 per family per year Occupational therapy assessment – 1 per beneficiary per year (ages 3-12 years) Baby growth assessment at a contracted pharmacy clinic – 3 per beneficiary per year (ages 0-35 months)

Discipline	Description
Specialist consultations	Specialist consultations must be referred by a Network Provider and approved by Bestmed. Limited to M = R1 000 M1+ = R 1 500 Subject to Pulse specialist DSP network R500 penalty for non-referral to specialists in PMB cases
Medical aids, apparatus and appliances including wheelchairs and hearing aids and appliances	No benefit
Supplementary services (Services rendered by dieticians, chiropractors, homeopaths, orthoptists, acupuncturists, speech therapists, audiologists, occupational therapists, chiropodists, biokineticists, psychologists and social workers)	No benefit
Wound care benefit (incl. dressings, negative pressure wound therapy (NPWT) treatment and related nursing services – out-of-hospital)	No benefit
Specialised diagnostic imaging	No benefit
Oncology	PMBs only, state facilities where available
Peritoneal dialysis and haemodialysis	PMBs only at DSPs
Rehabilitation services after trauma	No benefit

Chronic Disease List (CDL)
CDL 1	Addison’s disease
CDL 2	Asthma
CDL 3	Bipolar mood disorder
CDL 4	Bronchiectasis
CDL 5	Cardiomyopathy
CDL 6	Chronic renal disease
CDL 7	Chronic obstructive pulmonary disease (COPD)
CDL 8	Cardiac failure
CDL 9	Coronary artery disease
CDL 10	Crohn’s disease
CDL 11	Diabetes insipidus
CDL 12	Diabetes mellitus type 1
CDL 13	Diabetes mellitus type 2
CDL 14	Dysrhythmias
CDL 15	Epilepsy
CDL 16	Glaucoma
CDL 17	Haemophilia
CDL 18	Hyperlipidaemia
CDL 19	Hypertension
CDL 20	Hypothyroidism
CDL 21	Multiple sclerosis
CDL 22	Parkinson’s disease
CDL 23	Rheumatoid arthritis
CDL 24	Schizophrenia
CDL 25	Systemic lupus erythematosus (SLE)
CDL 26	Ulcerative colitis

Prescribed Minimum Benefits (PMB)
PMB 1	Aplastic anaemia
PMB 2	Chronic anaemia
PMB 3	Benign prostatic hypertrophy
PMB 4	Cushing’s disease
PMB 5	Cystic fibrosis
PMB 6	Endometriosis
PMB 7	Female menopause
PMB 8	Fibrosing alveolitis
PMB 9	Graves’ disease
PMB 10	Hyperthyroidism
PMB 11	Hypophyseal adenoma
PMB 12	Idiopathic thrombocytopenic purpura
PMB 13	Paraplegia/Quadriplegia
PMB 14	Polycystic ovarian syndrome
PMB 15	Pulmonary embolism
PMB 16	Stroke

With so many things to juggle, the Maternity Care programme is here to help moms and dads through their entire pregnancy and the first two years with a new little one in the home. At Bestmed, we want you to enjoy this entire experience and feel comfortable knowing that we are here for you.

Registering on this programme will give you the following support and benefits:

• A 24-hour professional medical advice line you can call with any queries, no matter how small.
• Weekly e-mails packed with convenient information about your pregnancy, your baby’s development, how to deal with unpleasant pregnancy symptoms and useful hints.
• Dads won’t be left out as they will also receive e-mails every second week to inform them about the baby’s development and Mom’s progress.
• To make sure your pregnancy starts right, you will receive a welcome pack containing an informative pregnancy book to guide you through the stages as well as discount vouchers for various baby items.
• In your second month after registration, we will send you a useful baby bag packed with products to use after your baby’s birth.

You are able to register on the Maternity Care programme simply by sending an e-mail to [email protected] or you can call us on 086 111 1936.

Please note that you may only register after the 12th week of pregnancy