Bestmed Pulse 2 Option

The Bestmed Pulse 2 option is a comprehensive network option ideal for mature families that has advanced healthcare needs. This option provides unlimited cover for hospitalisation at a network of hospitals (mainly Netcare) and primary care services at a network of providers.

If you need chronic treatment and day-to-day benefits you will first have to consult a network family practitioner (FP) for referral.

Who should not choose this option?

The Bestmed Pulse 2 option is not suited for young couples with families. To get more value, check out the Beat and Pace ranges.

Bestmed Pulse 2 Option Benefits

  • Savings Account: Unavailable
  • Day-to-day Benefits: Available
  • Over the Counter: Available

Value Benefits

  • Preventative care
  • FP & Specialist consultations
  • Optometry
  • Dentistry
Contributions
Principal Member Adult Dependant Child Dependant*
Risk Amount R4 732 R4 732 R1 124
Savings Amount R0 R0 R0
Total Contribution R4 732 R4 732 R1 124

* You only pay for a maximum of four children. All other children can join as beneficiaries of the Scheme free of charge.

Method of Benefit Payment

On the Bestmed Pulse 2 option in-hospital services are paid from Scheme risk benefit. The Bestmed Pulse 2 network covers most out-of-hospital services. Some day-to-day services and preventative care services are available from the Scheme risk benefit.

Bestmed Pulse 2 members must make use of the Pulse Specialist DSP network.

In-hospital Benefits

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

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.

Voluntary use of a non-DSP hospital (except in the case of an emergency) will result in a co-payment of up to R10 000 for the member’s account.

Process for hospital authorisation

  • All members on the Bestmed Pulse 2 option must make use of Bestmed family practitioners (FPs)
  • The Bestmed network FP will refer the member to a Bestmed DSP specialist should a specialist consultation be required
  • Should the Bestmed DSP 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 in-hospital benefits referred to in the section below require pre-authorisation from Bestmed
  • Bestmed clinical funding protocols and limits may apply
Medical Event Scheme Benefit
Accommodation (hospital stay) and theatre fees 100% Scheme tariff at designated service provider (DSP) hospital
Take-home medicine 100% Scheme tariff
Limited to 7 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 or R27 200 per beneficiary
Subject to network facilities
Consultations and procedures 100% Scheme tariff
Surgical procedures and anaesthetics 100% Scheme tariff
Organ transplants 100% Scheme tariff (Only PMBs)
Major medical maxillo-facial surgery strictly related to certain conditions 100% Scheme tariff
Dental and oral surgery 100% Scheme tariff
Prosthesis
(Subject to preferred provider, otherwise limits and co-payments apply)
100% Scheme tariff.
Limited to R89 500 per family
Prosthesis – Internal
Note: Sub-limit subject to the prosthesis limit
Sub-limits per beneficiary:

  • *Functional limited to R14 850
  • Vascular: R34 600
  • Pacemaker (dual chamber): R46 900
  • Endovascular and catheter-based procedures – no benefit
  • Spinal: R34 600
  • Artificial disk: R15 200
  • Drug-eluting stents: R15 200
  • Mesh: R15 200
  • Gynaecology/Urology: R11 300
  • Lens implants: R9 700 per lens
  • Joint replacements:
    • 1: Hip replacement and other major joints: R41 400
    • 2: Knee replacement: R48 350
    • 3: Minor joints: R18 000
Prosthesis – External Limit of R21 600 per family
Orthopaedic and medical appliances 100% Scheme tariff
Pathology 100% Scheme tariff
Diagnostic imaging 100% Scheme tariff
Specialised diagnostic imaging 100% Scheme tariff
Oncology 100% Scheme tariff
Oncology Programme and Designated Service Provider (DSP)
MRP applies to medicine claims where applicable
The Designated Service Provider is ICON
Peritoneal dialysis and haemodialysis 100% Scheme tariff
Only DSPs
Subject to pre-authorisation
Confinements 100% Scheme tariff
Refractive surgery 100% Scheme tariff
Limited to R7 950 per eye
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 of up to R10 000 per event for voluntary use of a non-DSP hospital
Out-of-hospital Benefits

Most out-of-hospital benefits are paid through Bestmed at the 100% negotiated contract tariff.

The Bestmed FP and Pulse dental networks are conveniently located across South Africa.

Members on Bestmed Pulse 2 are required to make use of the Bestmed FP provider network for primary healthcare services.

Bestmed Pulse specialist DSP Network

All members must use the Bestmed Pulse specialist DSP Network as the contracted Designated Service Provider (DSP).

Medical Event Scheme Benefit
Overall Day-to-day Limit M = R12 250, M1+ = R24 350
FP Consultations Unlimited, FP visits at a Bestmed FP network provider:

Out-of-Network:

  • FP visits (subject to overall day-today limit)
  • Limited to maximum 2 casualty visits per family up to a maximum of R1 300 per visit
  • Member to pay for the visit up front and then claim back from Bestmed Medicines and all associated costs relating to the visit are also paid from the R1 300 limit
Specialist Consultations 100% Scheme tariff

Limited to M = R2 700, M1+ = R5 200
(subject to overall day-to-day limit)

Referral by the network FP is required for specialist consultations

Subject to Bestmed Pulse Specialist DSP

Minor procedures performed in the provider’s rooms must be pre-approved by Bestmed.

Basic & Specialised Dentistry Basic Dentistry:
100% Scheme tariff – subject to the Bestmed Pulse 2 approved tariff listSpecialised Dentistry:100% Scheme tariff – subject to overall day-to-day limit)Limited to M = R6 1250, M1+ = R7 800Exclusions Apply:

  • Orthodontic therapy above 21 years
  • Complications with removable dentures
  • MRI and CT scans for any dentoalveolar procedures
Dentures Limited to a maximum of two removeable acrylic dentures (i.e. two single denture plates) per family every 24 months

At Bestmed Pulse network dental provider and accredited dental laboratories and in accordance with the Bestmed Pulse 2 list of approved codes only

Medical aids, apparatus and appliances including wheelchairs and hearing aids 100% Scheme tariff. Limited to R8 700 per family.
Limit on wheelchairs of R11 200 per family per 48 months.
Limit on hearing aids of R24 200 per beneficiary per 24 months at DSP.
Subject to quotation, motivation and audiogram.
Supplementary Services
(Services rendered by dieticians, chiropractors, homeopaths, orthoptists, acupuncturists, speech therapists, audiologists, occupational therapists, chiropodists, biokineticists, psychologists and social workers)
100% Scheme tariff
Limited to M = R3 600, M1+ = R7 150 – subject to overall day-to-day limit
Must be referred by a network provider only.
Maternity Benefits 2 sonars and up to 12 antenatal consultations
Wound Care Benefit
(incl. dressings, negative pressure wound therapy (NPWT) treatment and related nursing services – out-of-hospital)
100% Scheme tariff
Limited to R8 400 per family
Optometry PPN Benefits
(PPN capitation provider)
100% Scheme tariff

  • Consultation R365
  • Frame R550 AND
  • Single vision lens: R175 OR
  • Bifocal lens: R380 OR
  • Multifocal lens: R695
  • Contact lenses: R1 420
Diagnostic Imaging & Patholog 100% Scheme tariff.
Primary care pathology and radiology must be requested via the network FP according to the network approved Pulse 2 protocols and tariff list.
(Subject to overall day-to-day limit)
Specialised Diagnostic Imaging 100% Scheme tariff

  • MRI/CT scans: Maximum of 3 scans per beneficiary
  • PET scan: 1 scan per beneficiary

Subject to pre-authorisation

Oncology 100% Scheme tariff
Oncology Programme and Designated Service Provider (DSP)
MRP applies to medicine claims where applicable
The DSP is ICON
Peritoneal Dialysis & Haemodialysis 100% Scheme tariff
Subject to pre-authorisation and DSPs
National Renal Care (NRC)
Rehabilitation Services After Trauma No benefit
Medicine
  • All benefits below are subject to approval, pre-authorisation, formularies, funding guidelines and the Mediscor Reference Price (MRP).
  • Please note that approved CDL, PMB and non-CDL chronic medicine costs will be paid from the non-CDL chronic limit. Thereafter, approved CDL and PMB chronic medicine costs will continue to be paid (unlimited) from Scheme risk.
Benefit Description Scheme Benefit
CDL & PMB chronic medicine 100% Scheme tariff – unlimited
Must be prescribed by a network provider and obtained from a network pharmacy
Co-payment of 25% for non-formulary medicine
Non-CDL chronic medicine 85% of Scheme tariff
16 conditions
Limited to M = R5 800, M1+ = R11 600
Must be prescribed by a network provider and obtained from a network pharmacy
Co-payment of 25% for non-formulary medicine
Biologicals and other high-cost medicine 100% Scheme tariff
Limited to R132 000 per beneficiary
Acute medicine 100% Scheme tariff
Limited M = R3 850, M1+ = R7 800
(Subject to overall day-to-day limit)
Must be prescribed by a network provider and obtained from a network pharmacy
No benefit for medicine not on the acute medicine formulary
Over-the-counter (OTC) medicine 100% Scheme tariff
Limited to R550 per family. (Subject to acute medicine limit and available funds in the overall day-today limit)
Subject to provider network formulary

Preventative Care Benefits

100% Scheme tariff. Subject to Scheme protocols. Benefits below may be subject to 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
Paediatric Immunisations Babies & children Funding for all paediatric vaccines according to the
state-recommended programme
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
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)
Chronic / Non-Chronic Conditions List (CDL / Non-CDL)
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
Non-Chronic Disease List (Non-CDL)
Non-CDL 1 Acne – severe
Non-CDL 2 Attention deficit disorder/ Attention deficit hyperactivity disorder (ADD/ADHD)
Non-CDL 3 Allergic rhinitis
Non-CDL 4 Eczema – severe
Non-CDL 5 Migraine prophylaxis
Non-CDL 6 Gout prophylaxis
Non-CDL 7 Major depression
Non-CDL 8 Obsessive compulsive disorder
Non-CDL 9 Osteoporosis
Non-CDL 10 Psoriasis
Non-CDL 11 Urinary incontinence
Non-CDL 12 Paget’s disease
Non-CDL 13 Gastro oesophageal reflux disease (GORD)
Non-CDL 14 Osteoarthritis
Non-CDL 15 Alzheimer’s disease
Non-CDL 16 Neuropathy
Prescribed Minimum Benefits (PMB)
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
Maternity Care Programme

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