User login

You are here

Home

ProActive 2021

Add to compare
Type of Medical Aid Plan: 
Hospital
Medical Aid Year: 
2021
Day to day Benefits: 

There is a dentistry benefit of R612 per beneficiary to a maximum of R1 748 per family

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 PMB's
Specialists: 
Unlimited at Specific Tariff, which is a specific Rand value
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited at 100% of Profmed Rate(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-hospital only
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. R233 078 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: 
Subject to PMB's
Maternity Confinements: 
100% of NT in a general ward. Normal delivery 3 days, Caesarean 4 days
In Hospital Dentistry: 
100% of NT for wisdom teeth and extensive dental treatment for children younger than 8 years. Pre-authorisation required
Take home Medicine: 
Subject to PMB's
Rehabilitation, Hospice and Step-down facilities: 
100% of NT. Subject to pre-authorisation and DSP. Limited to R27 387 per family per annum. Out-patient care in-lieu of hospitalisation at a sub-acute facility or at home by a registered practitioner R12 818
Treatment for Mental Health: 
In-hospital: 100% of NT in a general ward. Subject to pre-authorisation PMB's and DSP. Limited to R20 627 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: 
R2.5m per beneficiary per journey for in-hospital emergency medical expenses. Subject to Scheme Protocols and pre-authorisation with International SOS
Day-to-day benefits
GP consultations: 

No benefit

Specialist consultations: 

No benefit

Acute medicine: 

No benefit

Over-the-counter (OTC) Medicine: 

No benefit

Optometry benefits: 
No benefit
Basic dentistry: 
135% of PT. R612 per beneficiary to a maximum of R1 748 per family
Specialised Dentistry: 
No benefit
Orthodontics: 

No benefit

MRI and CT Scans (Out of Hospital): 
No benefit
Radiology and Pathology: 
No benefit
Pregnancy benefits: 
Subject to PMB's
Physiotherapy and Occupational Therapy day to day: 
No benefit
Chronic Conditions
Provider: 
Profmed Pharmacy Network, ProActive 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: 
None
Preventative Care Benefits
Preventative Benefits: 

Females; HPV vaccine 9-27 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: immunisations per Department of Health Schedule- vaccine only 0-12 years: All beneficiaries; flu vaccine, fasting lipogram and fasting blood sugar above 40 years and Pneumococcal vaccine above 65 years

Total Contributions
Total Contribution Main Member: 
1923.00
Total Contribution Adult: 
1777.00
Total Contribution Child*: 
749.00
ProActive
Medical Aid Plan Name Term: 
ProActive