PULA has continuously believed in providing products that are simple and yet serve the needs of its customers and clients. This ethos has seen the development of three (3) major benefit options which are primarily intended to serve the medical aid needs of all tiers of the economic sector, these options are; The Standard Benefit Option which caters for small medium and micro enterprises and individuals at P40,000 cover per family per annum, the De-luxe Benefit Option- caters for the middle to upper income individuals and companies who seek comprehensive cover for their employees.
The P1.2 Million Comprehensive cover ensures that employees and individuals gain access to a wider variety of services including out-patient, in-patient (hospitalization), acute and chronic medicines, and the dread disease benefit which ensures access to medical assistance for specified diseases and or medical conditions, and lastly the Executive Option which is targeted at individuals and top executives in companies providing cover of P2 Million per family per annum.
With effect from 1 July 2017, the Fund introduced two additional benefit Options ; Flexi Benefit Option which is a P60,000 outpatient benefit Option targeting very low income market, the Galaxy Benefit Option which caters for middle income earners with a P100,000 cover per family per annum.
In addition to these benefits PULA also offers a variety of additional benefits such as Travel Insurance, Emergency Medical services, Funeral covers, Premium waivers and preventative covers.
- Total Cover
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Covered Conditions Executive Option Deluxe Option Annual Overall Limit (Annual Basic Limit + Dread Disease Cover) BWP 2 000 000 BWP 1 2000 00 Annual Basic Limit (what you can use for day to day medical conditions) BWP 1 300 00 BWP 700 000 Dread Disease Cover (cover for specifics medical conditions) BWP 700 000 BWP 500 000
Consultations
- Medical Practitioners
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Covered Conditions Executive Option Deluxe Option General Practitioner consultation visits Up to P1,300,000 Up to P200,000 Medical specialist consultation visits Up to P1,300,000 Up to P200,000 Physiotherapy Up to P1,300,000 Up to P200,000 Anaesthetics Up to P1,300,000 Up to P200,000 Non-surgical procedures and Operations Up to P1,300,000 Up to P200,000 Other related professional services Up to P1,300,000 Up to P200,000
- Diagnostics
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Covered Conditions Executive Option Deluxe Option Diagnostic Pathology Up to P1,300,000 Up to P200,000 Diagnostic Radiology Up to P1,300,000 Up to P200,000 MRI and CT scans Up to P1,300,000 Up to P200,000
Medicines
- Prescribed Medicines and Injection Material
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Covered Conditions Executive Option Deluxe Option Overall Medicines Limit
Up to P10,000 Up to P8,600 Pharmacy Only Medicines (Over the Counter medicines) as scheduled (DRSA) Up to P3,000 Up to P2,580 Prescription Only Medicines as scheduled (DRSA) Up to P7, 000 Up to P6,020 Injection materials supplied by a medical practitioner, Dentists or authorised health professional Up to annual overall medicines limit Up to annual overall medicines limit Psychiatric Medicines P20,000 P15,000 Chronic Medication P20,000 per person covered in the family P15,000 per person covered in the family HIV/AIDS P20,000 ( includes antiretroviral drugs, monitoring tests, CD4+ and Viral load) P20,000 ( includes antiretroviral drugs, monitoring tests, CD4+ and Viral load)
- Hospital Admission
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Covered Conditions Executive Option Deluxe Option Private and government hospitals (in-patients) Subject to preauthorisation and Case Management Subject to preauthorisation and Case Management Hospitalisation (General and surgical wards) Up to P1,300,000 or balance thereof Up to P500,000 or remaining balance Intensive Care Unit or High Care Up to P1,300,000 or balance thereof Up to P500,000 or remaining balance Recovery Room Fees Up to P1,300,000 or balance thereof Up to P500,000 or remaining balance Medicines , materials & apparatus during your hospital admission Up to P1,300,000 or balance thereof Up to P500,000 or remaining balance Theatre Fees Up to P1,300,000 or balance thereof Up to P500,000 or remaining balance Prosthesis used in Surgery Up to P80,000 per case per annum Up to P60,000 per case per an
- Nursing and Home Based Services
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Covered Conditions Executive Option Deluxe Option Consulting Nurse (Family Nurse Practitioner) At a consultation tariff equivalent to half that of a general medical practitioner and up to annual basic limit At a consultation tariff equivalent to half that of a general medical practitioner and up to annual basic limit Step-down Facility / Nursing Homes Maximum of 42 days in any one (1) financial
year and at agreed price with the facilityMaximum of 42 days in any one (1) financial
year and at agreed price with the facilityHome-based Nursing Up to P6,600 depending on the family size Up to P3,600 depending on the family size
- Other Medical Services
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Covered Conditions Executive Option Deluxe Option Audiology and / or Speech Therapy P15,000 per family per annum P7,200 per family per annum Dietician (Doctor’s referral required) P15,000 per family per annum P7,200 per family per annum Clinical Psychology P15,000 per family per annum P7,200 per family per annum Occupational Therapy P15,000 per family per annum P7,200 per family per annum Chiropody Ambulance (Inter-hospital transfer only) P4,000 per case P3,500 per case Blood Transfusion Up to annual basic limit Up to P200,000 Medical Assistive Devices P30,000 per family per annum P20,000 per family per annum Medical and Surgical Appliances Up to P5,600 depending on the family size. Subject to pre-authorisation. P1,200 (Subject to pre-authorisation) Wheel chair P3,500 per beneficiary once every three (3) years P3,500 per beneficiary once every three (3) years
- Emergency Medical Services
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Covered Conditions Executive Option Deluxe Option Service is provided by Emergency Assist 991 (EA991), includes home and traffic related accidents, hospital transfers* etc Available to covered family members at NO co-payment Available to covered family members at NO co-payment
- Alternative Treatments
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Covered Conditions Executive Option Deluxe Option Associated Health Services P2,300 for anyone or a combination P1,725 Chiropractic (form of treatment concerned with diagnosis and
treatment of musculoskeletal disorders)P2,300 for anyone or a combination P1,725 Homeopathy/Naturopathy (form of treatment using small doses of natural substances that in larger amounts would produce
symptoms of the ailment)P2,300 for anyone or a combination P1,725 Acupuncture (A Chinese treatment using very small needles) P2,300 for anyone or a combination P1,725
- Child Birth
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Covered Conditions Executive Option Deluxe Option Child birth (Confinement) Subject to preauthorisation and Case Management (You will need to contact our Managed Care department ) we also offer you to join the PulaBaby Maternity programme Subject to preauthorisation and Case Management (You will need to contact our Managed Care
department ) we also offer you to join the PulaBaby Maternity programmeNormal delivery P10,000 P9,072 Caesarean section (C section) P16,500 P14,060 Surgical Contraception Subject to annual basic limit “Up to P500,000 or balance
- Normal Dentistry
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Covered Conditions Executive Option Deluxe Option Maxilo-facial & oral surgery Up to annual basic limit and upon referral by medical doctor “Up to annual basic limit but limited to P200,000 per member” Conservative dentistry including Plastic based dentures Up to annual basic limit but limited to
P200, 000 per memberUp to annual basic limit” Specialised Dentistry Inlays, crowns, bridgework, study models, metal base dentures and their repair, periodontics,
prosthodontics and orthodonticsP20,000 P10,000
- For Your Eyes
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Covered Conditions Executive Option Deluxe Option Optical Spectacles and or Contact lenses and Contact lenses Solutions P3,500 per family member every 2
years (Frame limited to P1,750)P3,000 per family member every 2 years(Frame limited to P1,500) Eye test by optometrist At agreed price with optician At agreed price with Optician Orthoptistry P1,600 P1,600
- Prevention
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Preventive Care Annual medical examination inclusive of screening tests Annual medical examination inclusive of screening tests Safe Male Circumcision (HIV Prevention only) At agreed tariff subject to preauthorization At agreed tariff, subject to
pre-authorisation
- Drug Rehabilitation
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Covered Conditions Executive Option Deluxe Option Alcoholism and Drug addiction P 30 000 per family per annum, subject to pre-authorisation P20,000 per family per annum
- Additional Benefits
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Covered Conditions Executive Option Deluxe Option International Travel Insurance (P2 Million) √ √ Maternity Programme (PulaBaby) √ √ Funeral Pay-out (in the event a member of your family passes on, we will pay-out to a nominated beneficiary) √ √ Premium Waiver (Your loved ones will remain covered for 6 months at no cost in the instance you pass on) √ √ Loyalty Programme (Value Add)- get discounts from a select number of our partners when you produce your Pula card √ √
- Dread Disease Cover
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The Dread Disease Cover is available to members of the Executive and De-luxe Benefit Options. The Dread Disease Cover annual limit is P500 000 per family for the Deluxe Option and P700 000 per family for the Executive Option.
Qualifying Condition and Description
Heart Attack
The death or final cessation of a full thickness portion of the heart muscle, due to in adequate blood supply to the relevant. The diagnosis will be based on the following criteria.
i. A history of typical chest pain
ii. New ECG changes and
iii. The elevation of cardiac enzymesCoronary Heart Disease
Open by-pass surgery or surgical treatment of a coronary disease.
Stroke
Any cerebrovascular occurrence which produces neurological sequel which lasts more than 24 successive hours and produces evidence of permanent neurological deficit, included herein shall be infraction (localized death because of inadequate blood supply) of brain tissue, intracranial (within the skull) and or subarachnoid hemorrhage and embolization (sudden blocking of blood vessels) from an extra cranial source.
Cancer
A disease manifested by the presence of malignant tumor characterized by the uncontrolled growth and spread of malignant cells, and invasion of normal surrounding tissue, except, that, cancers diagnosed and treated by primary biopsy only: that is, not requiring any further surgical, medical (chemotherapy etc) or radio- therapy, or other modalities are excluded. These excluded treatment areas will continue to be covered under basic /ordinary annual limits. For ‘dread disease’ purposes, the term Cancer shall also include leukemia and Hodgkin’s Disease (enlargement of lymph glands in the spleen, liver etc) but shall exclude all skin cancers; except invasive and malignant melanomas. As with biopsies etc treatment of skin cancer will be paid out of the base (ordinary) annual limits.
Kidney Failure
End stage renal failure presenting as chronic irreversible failure of both kidneys to function, as a result of which regular renal dialysis must be instituted.
Organ Transplant
The human to human transplant from a donor to the Fund’s beneficiary, of one or more of the following organs:
i. Kidney
ii. Heart
iii. Lung
iv. Pancreas
v. Bone Marrow
vi. LiverThe transplant of all or other organs, parts of organs or any other tissue transplant is excluded.
Paraplegia
The total and irreversible loss of the use of both limbs.
Systemic Lupus Erythematous (SLE)
A chronic autoimmune disease that affects different parts of the body including heart, lungs , blood vessels, muscles, joints, kidneys, and the nervous system. Manifestation differs from person to person.
Multiple Sclerosis
A disease or diagnosis by a suitably qualified specialist practitioner of the central nervous system, characterized by disseminated patches of demyelination (destroyed myelin tissue) in the brain or spinal cord-resulting in multiple neurological symptoms and signs, with remissions and exacerbations.
Motor Vehicle/ Road Traffic Accident
Treatment emanating from, or as a cause of the patient having been involved in a road traffic accident. The Fund’s exposure will be limited to the extent of Annexure C Rule 2.8 (of the existing Rules) which provides that any other party (such as Motor Vehicle Accident Fund) who is liable fully or in part will contribute to treatment costs.
Hepatitis C
Treatment of chronic Hepatitis C as per standard treatment guidelines.
- Total Cover Breakdown
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Annual Overall Limit (Annual Basic Limit + Dread Disease Cover) BWP 100,000 BWP 60,000 BWP 40,000 Annual Basic Limit (what you can use for day to day
medical conditions)BWP 100,000 BWP 60,000 BWP 40,000 Dread Disease Cover (cover for specifics medical conditions) X X X
- Consultations
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Medical Practitioners General Practitioner consultation visits Up to P2,000 Up to P1,500 Up to annual basic limit Medical specialist consultation visits Up to P4,000 Up to P1,500 Up to annual basic limit Physiotherapy Up to P10,000 Up to P9,000 Up to annual basic limit Anaesthetics Up to annual basic limit per family X Up to annual basic limit Non-surgical procedures and Operations Up to annual basic limit per family or balance thereof X Up to annual basic limit per family or balance thereof Other related professional services Up to annual basic limit per family X Up to annual basic limit
- Diagnostics
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Diagnostic Pathology Up to P10,000 Up to P5,000 Up to annual basic limit Diagnostic Pathology Up to P10,000 Up to P7,000 Up to annual basic limit MRI and CT scans X X Up to annual basic limit
Medicines
- Prescribed Medicines and Injection Material
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Overall Medicines Limit Up to P6,182 Up to 4, 000 Up to P6,182 depending on the family size Pharmacy Only Medicines (Over the Counter medicines) as scheduled (DRSA) Up to P1,855 Up to 2, 000 Up to P1,855 depending on
the family sizePrescription Only Medicines as scheduled (DRSA) Up to P4,327 Up to 2, 000 Up to P4,327 depending on
the family sizeInjection materials supplied by a medical practitioner, Dentists or authorised health professional Up to annual overall
medicines limitUp to 2, 000 Up to annual overall medicines limit Psychiatric Medicines P9,700 P2,270 Chronic Medication P9,700 per person
covered in the familyP9,700 per person
covered in the familyX HIV/AIDS P9,700 per person
covered in the familyP9,700 per person
covered in the familyX
- Hospital Admissions
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Private and government hospitals (in-patients) Subject to preauthorisation and Case Management
X Up to P40,000 or remaining Hospitalisation (general and surgical ward) Up to P50,000 or remaining balance
X Up to P40,000 or remaining Intensive Care Unit or High Care Up to P50,000 or remaining balance
X Up to P40,000 or remaining Recovery Room Fees Up to P50,000 or remaining balance
X Up to P40,000 or remaining Medicines , materials & apparatus during your hospital admission Up to P50,000 or remaining balance
X Up to P40,000 or remaining Theatre Fees Up to P50,000 or remaining balance
X Up to P40,000 or remaining Prosthesis used in Surgery P4,500 per case per annum X P4,500 per case per annum
- Nursing and Home Based Services
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Consulting Nurse (Family Nurse Practitioner) At a consultation tariff equivalent to half that of a general medical practitioner and up to annual basic limit
X At a consultation tariff
equivalent to half that of a
general medical practitioner
and up to annual overall limitStep-down Facility / Nursing Homes X X X Home-based Nursing X X X
- Other Medical Services
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Audiology and / or Speech Therapy P4,800 per family per annum X P4,800 per family per annum Dietician (Doctor’s referral required) P4,800 per family per annum X P4,800 per family per annum Clinical Psychology P4,800 per family per annum X P4,800 per family per annum Occupational Therapy P4,800 per family per annum X P4,800 per family per annum Chiropody P4,800 per family per annum X P4,800 per family per annum Ambulance (Inter-hospital transfer only) Up to P1,250 depending on the family size
X Up to P1,250 depending on the family size Blood Transfusion Up to annual overall medicines limit
X Up to annual overall limit Medical Assistive Devices X X X Medical and Surgical Appliances Up to P1,250 depending on the family size X Up to P1,250 depending on the family size Wheel chair X X
- Emergency Medical Services
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Service is provided by Emergency Assist 991 (EA991), includes home and traffic related accidents, hospital transfers* etc
Available to covered
family members at NO co-paymentAvailable to covered family
members at NO co-paymentAvailable to covered family members at NO co-payment
Alternative Treatments
- Associated Health Services
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Chiropractic (form of treatment concerned with diagnosis and treatment of musculoskeletal disorders) P1,000 P1,000 P785 Homeopathy/Naturopathy (form of treatment using small doses of natural substances that in larger amounts would produce symptoms of the ailment) P1,000 P1,000 P785 Acupuncture (A Chinese treatment using very small needles) P1,000 P1,000 P785
Planning To Have A Child
- Child Birth
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Normal delivery P9,072 X P8,640 Caesarean section (C-section) P14,060 X P13,650 Surgical Contraception At agreed tariff subject to pre-authorization X X
Taking Care Of Your Teeth
- Normal Dentistry
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Maxilo-facial & oral surgery P3,500-P5,000 P2,000-P3,500 Up to annual overall limit Conservative dentistry including Plastic based dentures
- Specialized Dentistry
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Inlays, crowns, bridgework, study models, metal base dentures and their repair, periodontics, prosthodontics and orthodontics P3,000 Not available P3,500
For Your Eyes
- Normal Dentistry
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Optical At agreed tariff At agreed tariff At agreed tariff & up to overall limit Eye test by optometrist P385 P385 P385
- Orthoptistry
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Spectacles and or Contact lenses and Contact lenses Solutions “P1,400 per two(2) years” “P1,000 per two(2) years” “P1,400 per two(2) years”
- Prevention
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Safe Male Circumcision (HIV Prevention only) P9,072 At agreed tariff subject to pre-authorization At agreed tariff
- Drug Rehabilitation
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option Alcoholism and Drug addiction P2,200 X P2,200
Additional Benefits
- Normal Dentistry
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Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option International Travel Insurance X X X Maternity Programme (PulaBaby) √ √ √ Funeral Payout (in the event a member of your family passes on, we will payout to a nominated beneficiary) √ √ √ Premium Waiver (Your loved ones will remain covered for 6 months at no cost in the instance you pass on) √ √ √ Loyalty Programme (Value Add) √ √ √
