Profmed Proactive Plus medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
ProActive Plus
Quick Overview
Main: Adult: Child:
Total Cost pm: R1,751 R1,628 R683
Savings (per year): No savings option on this plan
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Children: Pay for all children
  • Scheme rate is generally 200%, and most day-to-day expenses are out-of-pocket.
  • Some dentistry and GP consults paid by scheme
  • Some specialised radiology out of hospital paid by scheme, with a co-payment
  • Preventative benefits such as mammograms and pap smears
  • R211,000 cancer cover
  • Travel insurance benefit
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
See full benefits below

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IN HOSPITAL PROCEDURES:
ProActive Plus
Benefits Gap benefits
Payout Rate for Specialists:
  • 200% scheme tariff
Fusion Gap:
  • Up to 700% scheme rate for specialists and other providers
  • In case of admission related to accident:
    -R300 per day, for days 1-13
    -R600 per day for days 14-20
    -R1,200 per day for days 21-30
  • R350pm per family. More Info or download application below.
Hospital Choice:
  • Unlimited
  • N/A
Specialised Radiology:
  • 2 per family
Fusion Gap:
  • No benefit
Supplementary Services: (Physio, etc)
  • Physio: 100% scheme tariff
Fusion Gap:
  • Up to 700% scheme rate for specialists and other providers
Transplants:
  • Donor: only PMBs, and only if recipient is Profmed member
  • N/A
Co-payments:
  • N/A
  • N/A
Alternatives to hospitals:
  • Treatment in registered sub-acute facility or at home: R11,627 per person
  • Wound care treatment at home: R3,065 per person
Casualty:
  • No benefit, unless PMB or if results in hospital admission
Other:
  • Post-hospital rehabilitation: R24,840 at DSP
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OUT OF HOSPITAL BENEFITS:
ProActive Plus
Benefits Gap benefits
GP consultations:
  • M =R1,000
  • M1= R1,600
  • M2+=R2,000
  • Out of hospital treatment for conditions that are PMBs is always paid for by the scheme (not out of savings), but according to protocols
Childcare:
  • Immunisations are covered by scheme
  • No benefit
Specialists consultations:
  • Shared with GP benefits, see above
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
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MATERNITY BENEFITS:
ProActive Plus
Benefits Gap benefits
Hospital stay:
  • 200% scheme rate
Consultations:
  • No benefit, unless PMB
Scans:
  • No benefit, unless PMB
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CANCER (ONCOLOGY):
ProActive Plus
Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R211,400 per person. Thereafter, only PMBs
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DENTISTRY:
ProActive Plus
Benefits Gap benefits
Dentistry:
  • Out of hospital: R550 per person and R1,585 per family
  • In-hospital: children younger than 8yrs and removal of impacted teeth
  • Orthognathic surgery: no benefit
Orthodontics:
  • See above
Maxillo Facial Surgery:
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MEDICATION:
ProActive Plus
Benefits Gap benefits
Chronic:
  • No. of chronic conditions covered: 27
Acute (presrcibed) medication:
  • No benefit, unless PMB
Over-the-counter:
  • No benefit
Birth Control:
  • R1,734 per person, for oral, patches, injections, implants and IUDs
On Discharge:
  • No benefit, unless PMB
Biological:
  • No benefit
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OPTOMETRY:
ProActive Plus
Benefits Gap benefits
Optometry:
  • No benefit, unless PMB
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MENTAL HEALTH:
ProActive Plus
Benefits Gap benefits
In-hospital:
  • R18,709 per person. Thereafter PMB only.
Out-of-hospital:
  • R6,342 per person. Subject to above limit, and PMBs only.
Trauma:
  • Telephone and face to face counselling, as appropriate
  • HIV post-exposure: 2 doctor consults, 30 days PEP medication, pathology and management
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OTHER BENEFITS:
ProActive Plus
Benefits Gap benefits
General Appliances:
  • Internal appliances: R48,622 per family
  • Cochlear implants: R61,306 per family
  • No benefit
1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • No benefit
  • No benefit
Dialysis:
  • Unlimited, at State chronic provider
HIV:
  • No benefit
Emergency Transport:
  • No benefit
International Insurance:
  • R6 million per person per journey
  • No benefit for out of hospital expenses
  • No benefit
Other:
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WELLNESS/PREVENTATIVE BENEFITS:
ProActive Plus
Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • Covered for 65yrs+
  • No benefit
Back Rehabilitation Programme:
  • No benefit
Biometric Screening:
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered for 18yrs+
  • No benefit
Mammogram:
  • Covered for 40yrs+ and those pre-disposed to breast cancer
  • No benefit
PAS Test:
  • Covered for 40yrs+
  • No benefit
HIV Test:
  • No benefit
Other:
  • Lipogram blood test, for 40yrs+
  • Fasting blood sugar test, for 40yrs+
  • HPV vaccine, for 9-27yrs
  • No benefit
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PROSTHETICS:
ProActive Plus
Benefits Gap benefits
Overal Limit:
Sub-limits:
  • An additional R40,000 per sublimit, per event

    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised