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Compare Benefits

Compare Benefits

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
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
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
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
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
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
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 facility
Maximum of 42 days in any one (1) financial
year and at agreed price with the facility
Home-based Nursing Up to P6,600 depending on the family size Up to P3,600 depending on the family size
Other Medical Services
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
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
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
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 programme
Normal 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
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 member
Up to annual basic limit”
Specialised Dentistry    
Inlays, crowns, bridgework, study models, metal base dentures and their repair, periodontics,
prosthodontics and orthodontics
P20,000 P10,000
For Your Eyes
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
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
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
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

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 enzymes

Coronary 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. Liver

The 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
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
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
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
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 size
Prescription Only Medicines as scheduled (DRSA) Up to P4,327 Up to 2, 000 Up to P4,327 depending on
the family size
Injection materials supplied by a medical practitioner, Dentists or authorised health professional Up to annual overall
medicines limit
Up to 2, 000 Up to annual overall medicines limit
Psychiatric Medicines P9,700   P2,270
Chronic Medication P9,700 per person
covered in the family
P9,700 per person
covered in the family
X
HIV/AIDS P9,700 per person
covered in the family
P9,700 per person
covered in the family
X
Hospital Admissions
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
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 limit
Step-down Facility / Nursing Homes X X X
Home-based Nursing X X X
Other Medical Services
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
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-payment
Available to covered family
members at NO co-payment
Available to covered family members at NO co-payment

Alternative Treatments

Associated Health Services
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
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
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
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
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
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
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
Covered Conditions Galaxy Option Flexi Option (out-patient cover) Standard Option
Alcoholism and Drug addiction P2,200 X P2,200

Additional Benefits

Normal Dentistry
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)