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ProActive Plus 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 = R3 581; M+1 = R5 122 and M+2+ = R6 508. GP and specialist consultations, emergency room visits, acute and over-the-counter medication, radiology, pathology, dentistry and an eye examination 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 200% 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-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. GP, specialist or midwife paid at 200% 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 200% 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 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: 

Subject to annual day-to-day limit of M = R3 581; M+1 = R5 122 and M+2+ = R6 508 and GP rate of R502

Specialist consultations: 

Subject to annual day-to-day limit and GP rate of R502

Acute medicine: 

Subject to annual day-to-day acute medicine limit. M = R628; M+1 = R942; M+2+ = R1 226. 80% of Single Exit Price plus dispensing fee

Over-the-counter (OTC) Medicine: 

Subject to annual day-to-day acute medicine limit. M = R628; M+1 = R942; M+2+ = R1 226. 80% of cost

Optometry benefits: 
100% Optical Tariff. Eye test only, once every 24 month cycle. Subject to Opticlear network provider and available day-to-day limit
Basic dentistry: 
135% of PT. Subject to available day-to-day limit
Specialised Dentistry: 
135% of PT. Subject to available day-to-day limit
Orthodontics: 

135% of PT. Subject to available day-to-day limit. Available to beneficiaries younger than 18 years

MRI and CT Scans (Out of Hospital): 
No benefit
Radiology and Pathology: 
Subject to available day-to-day limit. Paid at 80% of PR
Pregnancy benefits: 
Consultations are subject to available day-to-day limit and GP rate of R502. Prescribed medicines are subject to available acute medicine sub-limit. Paid at 80% of PR
Physiotherapy and Occupational Therapy day to day: 
Subject to PMB's
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: 
2283.00
Total Contribution Adult: 
2123.00
Total Contribution Child*: 
890.00
ProActive Plus
Medical Aid Plan Name Term: 
ProActive Plus