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.

ProActive Plus
2018 Costs:
Total Cost pm:

Main member:

R1,751

Adult:

R1,628

Child: (Pay for all)

R683
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

Child: (Pay for all)

R
In brief (2018):
  • 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

IN HOSPITAL PROCEDURES:
ProActive Plus
Scheme Benefits: Gap Benefits:
Specialists:
  • 200% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital
  • No benefit
Specialised Radiology:
  • 2 per family
  • No benefit
Supplementary Services: (Physio, etc)
  • Physio: 100% scheme tariff
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment
  • No benefit for out-of-hospital services
Transplants:
  • Donor: only PMBs, and only if recipient is Profmed member
  • No extra benefit available (PMB benefits are paid in full by medical aid)
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
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • Post-hospital rehabilitation: R24,840 at DSP
  • No benefit
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
ProActive Plus
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
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 extra benefit available
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
Scheme 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
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R211,400 per person. Thereafter, only PMBs
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DENTISTRY:
ProActive Plus
Scheme 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
  • No extra benefit available
Maxillo Facial Surgery:
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)
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MEDICATION:
ProActive Plus
Scheme 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
Scheme Benefits Gap benefits
Optometry:
  • No benefit, unless PMB
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)
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MENTAL HEALTH:
ProActive Plus
Scheme 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
Scheme 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:
  • Covered for emergencies
  • 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
Scheme 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
Scheme Benefits Gap benefits
Overal Limit:
  • An additional R40,000 per sublimit, per event
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