The Bestmed Pulse 1 option is ideal for individuals looking for medical aid that is adaptable to their income. This option will also not shy away from having to visit a set network of designated service providers. The Bestmed Pulse 1 option provides primary healthcare services, private hospital cover and some preventative care benefits.
Who should not choose this option?
The Bestmed Beat options is not suited for older individuals and families as they require more day-to-day expenses cover and certain diseases. If you need more cover from a medical aid, please refer to Bestmed’s Pace Options.
Bestmed Pulse 1 Option Benefits
- Savings Account: Unavailable
- Day-to-day Benefits: Available
- Over the Counter: Available
Value Benefits
- Preventative care
- FP & Specialist consultations
- Optometry
- Basic dentistry
| Monthly Income | Principal Member | Adult Dependant | Child Dependant |
|---|---|---|---|
| 0 – R5 500 p.m. | R1 372 | R1 303 | R824 |
| R5 501 – R8 500 p.m. | R1 645 | R1 565 | R987 |
| R8 501+ p.m. | R1 976 | R1 777 | R987 |
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:
|
| 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:
|
| 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:
|
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 |
|
||
| 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 info@babyhealth.co.za or you can call us on 086 111 1936.
Please note that you may only register after the 12th week of pregnancy
