Are you prepared to use designated hospitals?:
Hospital Rate of Payment:
Unlimited at 100% of Negotiated Tariff(NT)
Upfront Payments to hospitals:
R10 000 payment for voluntary use of a Non-Savvy Network Hospital
Casualty / Emergency Visits:
Subject to available day-to-day limit and PMB's
Specialists:
Unlimited at 100% of Profmed Tariff(PR)
Other healthcare professionals eg. Physio, Occupational, Dietician:
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
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. R466 155 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
Medical and Surgical Appliances:
100% of NT. R14 567 per family. Post-mastectomy bra limited to R700 and 2 per 1st year, then 1 per year. Hearing aids 1 per 2 years with an additional R6 875
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:
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 R54 774 per family per annum. Out-patient care in-lieu of hospitalisation at a sub-acute facility or at home by a registered practitioner R15 032
Treatment for Mental Health:
In-hospital: 100% of NT in a general ward. Subject to pre-authorisation PMB's and DSP. Limited to R27 503 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:
R5m 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