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ProPinnacle 2021

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Type of Medical Aid Plan: 
New Generation
Medical Aid Year: 
2021
Day to day Benefits: 

There is an annual day-to-day limit of M = R18 647; M+1 = R27 619 and M+2+ = R35 894. GP and specialist consultations, emergency room visits, acute and over-the-counter medication, radiology, pathology, dentistry and optometry are paid from the available day-to-day limit, subject to sub-limits

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% of Negotiated Tariff(NT)
Hospitals: 

Any. Designated Service Providers(DSP's) required for psychiatric hospitalisation, drug and alcohol rehabilitation, physical rehabilitation and endoscopic procedures

Upfront Payments to hospitals: 

None

Casualty / Emergency Visits: 
Subject to available day-to-day limit and PMB's
Specialists: 
Unlimited at 300% of Profmed Tariff(PR)
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited at 100% of PR
Radiology and pathology: 
Unlimited at 100% of PR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100% of NR. Subject to pre-authorisation and the use of a DSP network
MRI and CT scans: 
100% of PR. Subject to specialist referral and pre-authorisation. 2 investigations per family, in- or out-of-hospital
ICU and High Care: 
Unlimited at 100% of PR
Dialysis: 
100% of NR. Subject to registration on the Disease Management Programme, PMB's, DSP and pre-authorisation
Organ Transplants: 
100% of NR. Subject to registration on the Disease Management Programme, PMB's and pre-authorisation. No cover for the donor if the recipient is not a Profmed member
Oncology / Cancer: 
Subject to registration on the Disease Management Programme, PMB's, DSP and pre-authorisation. R699 233 per beneficiary
Neck and Back Operations: 
100% of NT. Subject to PMB's and prosthesis sub-limits
Joint Replacements: 
100% of NT. Subject to PMB's and prosthesis sub-limits
Prosthesis: 

Subject to PMB's, pre-authorisation, Scheme Protocols and management. 100% of NT limited to R53 608 per family for major surgery and intraocular lenses R5 070 per beneficiary per event

Medical and Surgical Appliances: 
100% of NT. R21 910 per family. Post-mastectomy bra limited to R700 and 2 per 1st year, then 1 per year. Hearing aids 1 per 24 months with additional R4 137
Maternity Confinements: 
100% of PT in a private ward. Normal delivery 3 days, Caesarean 4 days. GP, specialist or midwife paid at 300% of PT
In Hospital Dentistry: 
100% of NT for wisdom teeth and extensive dental treatment for children younger than 8 years. Pre-authorisation required. Specialist and anaesthetist paid at 300% of PT
Take home Medicine: 
80% of NT. Paid from available funds in the acute medicine benefit
Rehabilitation, Hospice and Step-down facilities: 
100% of NT. Subject to pre-authorisation and DSP. Limited to R82 395 per family per annum. Out-patient care in-lieu of hospitalisation at a sub-acute facility or at home by a registered practitioner R17 808
Treatment for Mental Health: 
In-hospital: 100% of NT in a general ward. Subject to pre-authorisation PMB's and DSP. Limited to R41 254 per family. Out-of-hospital: subject to in-hospital limit and a sub-limit of R6 992 per family
HIV / AIDS: 
100% of NT. Subject to a DSP, Scheme Protocols and case management
Ambulance Service: 
Netcare 911 in an emergency
International Travel Benefit: 
R8m per beneficiary per journey for in-hospital emergency medical expenses and R10 000 out-of-hospital expenses, with a co-payment of R2 000. Subject to Scheme Protocols and pre-authorisation with International SOS
Day-to-day benefits
GP consultations: 

Subject to available annual day-to-day limit of M = R18 647; M+1 = R27 619 and M+2+ = R35 894

Specialist consultations: 

Subject to available day-to-day limit 

Acute medicine: 

Subject to annual day-to-day acute medicine limit of M = R10 488; M+1 = R13 984; M+2 = R14 916; M+3 = R16 548 to a maximum of R19 579 per family. 80% of Single Exit Price plus dispensing fee

Over-the-counter (OTC) Medicine: 

Subject to annual day-to-day acute medicine limit and a sub-limit of R1 981 per family. 80% of cost

Optometry benefits: 
100% Optical Tariff. Benefit once every 24 month cycle. Subject to Opticlear network provider and available day-to-day limit. Frames limited to R1 306; spectacle lenses or contact lenses, limited to R3 205 per beneficiary
Basic dentistry: 
135% of PT. Subject to available day-to-day limit and sub-limit of R7 132 per beneficiary and a maximum of R14 265 per family. Not subject to day-to-day limit
Specialised Dentistry: 
135% of PT. Subject to available day-to-day limit and sub-limit of R7 132 per beneficiary and a maximum of R14 265 per family. Not subject to day-to-day limit
Orthodontics: 

135% of PT. Subject to available day-to-day limit and sub-limit of R7 132 per beneficiary and a maximum of R14 265 per family. Not subject to day-to-day limit. Available to beneficiaries younger than 18 years

MRI and CT Scans (Out of Hospital): 
80% of PR. Subject to specialist referral and pre-authorisation
Radiology and Pathology: 
Subject to available day-to-day limit. Paid at 80% of PR
Pregnancy benefits: 
Subject to registration on the Maternity Programme and day-to-day limit. 13 consultations at a GP, specialist or registered midwife at 300% of PT. 1x lactation and 1x nutrition consultation 1x nuchal translucency test and 2x 2D scans
Physiotherapy and Occupational Therapy day to day: 
100% of PT. Subject to available day-to-day limit with a sub-limit of M = R3 029 and a maximum of R5 244 per family
Chronic Conditions
Provider: 
Profmed Pharmacy Network, ProSecure formulary and reference pricing
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to approval by the Chronic Illness Benefit

Additional Chronic Conditions: 
32. Subject to Profmed formulary and reference price. Unlimited
Preventative Care Benefits
Preventative Benefits: 

Females; HPV vaccine 9-27 years, HPV screening test 25-65 years per 5 years, pap smear above 18 years, mammogram above 40 years, contraceptives to a maximum of R1 911 per beneficiary at a DSP pharmacy: Males; Prostate Specific Antigen above 40 years: Children: newborn hearing screening up to 6 weeks, immunisations per Department of Health Schedule- vaccine only 0-12 years: All beneficiaries; flu vaccine, HIV test, fasting lipogram and fasting blood sugar above 40 years, Pneumococcal vaccine, bone-density and faecal occult blood test above 65 years

Total Contributions
Total Contribution Main Member: 
8741.00
Total Contribution Adult: 
8108.00
Total Contribution Child*: 
2622.00
ProPinnacle
Medical Aid Plan Name Term: 
ProPinnacle