Additional Information on Benefits

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HOSPITALISATION

Hospitalisation refers to admission for treatment or a procedure that can only be undertaken in-hospital. Hospitalisation for the sole purpose of radiology or pathology will not be funded...

CHRONIC MEDICINE LIST (CML)

This list outlines the medication covered by Profmed medical aid scheme in respect of the Chronic Disease List (CDL) conditions. It is important that your doctor or pharmacist authorises...

CHRONIC DISEASE LIST (CDL)

PRESCRIBED MINUMUM BENEFIT CDL CONDITIONS: Addison's Disease, Asthma
Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy Disease, Chronic Obstructive Pulmonary...

TRAUMA AND HIV ASSISTANCE PROGRAMME

This programme provides members with 24-hour access to trauma counselling and/or HIV assistance in the event of a trauma, e.g. rape, hijacking, needle-stick injury or any traumatic...

EMERGENCY TRANSPORT

Profmed has partnered with Netcare 911 as the Designated Service Provider (DSP) to provide emergency medical assistance to members within South Africa. It is important to note that Profmed’s...

EMERGENCIES WITHIN SADC REGION

Emergency assistance requests from countries within the SADC Region: SADC Region refers to a group of countries in Southern Africa, i.e. Angola, Botswana, Democratic Republic of

INTERNATIONAL TRAVEL MEDICAL ASSISTANCE

What are the enhancements?
Rand limit has increased from R3 million to R6 million per beneficiary per journey,
Members are no longer required to activate cover prior to departure,
If required, embassy letters...

MULTIPLY WELLNESS AND REWARDS PROGRAMME

The Multiply Wellness and Rewards Programme encourages members to lead a healthy lifestyle by providing incentives (such as discounts on gym membership, points for undergoing preventative medical tests etc.)...

PREVENTATIVE CARE

As part of our commitment to your wellbeing, this benefit encourages the early detection of the most frequently diagnosed high-risk diseases. Early treatment reduces the risk of complications and is...

CONTRACEPTIVES

This benefit is subject to a benefit limit per beneficiary and is paid from risk, at 100% Single Exit Price and dispensing fee at DSPN rate. MMAP® applies. Subject to annual sub-limit. This...

Hospitalisation

Hospitalisation refers to admission for treatment or a procedure that can only be undertaken in-hospital. Hospitalisation for the sole purpose of radiology or pathology will not be funded. Deposits are not required on admission to hospital.

Cover for hospitalisation includes the cost of hospital facilities, e.g. ward fees and theatre fees as well as materials, medicines (excluding medicine taken home on discharge) as these fees are controlled either by legislation, in the case of medicine, or negotiation by Profmed with the various hospitals and hospital groups.

Before a beneficiary can be admitted to hospital for an elective procedure, it is the member’s responsibility to obtain authorisation by calling 0860 776 363.

Click here for information on how to obtain pre-authorisation for hospital admission.

Multiply Wellness and Rewards Programme

The Multiply Wellness and Rewards Programme encourages members to lead a healthy lifestyle by providing incentives (such as discounts on gym membership, points for undergoing preventative medical tests etc.), and rewarding members when certain levels of fitness or wellness are achieved.

All Profmed members have automatic access to Multiply Starter, at no cost, which offers a number of exciting rewards and discounts on certain products. Members have the option to upgrade to Multiply Provider or Multiply Premier, which offers a wider range of benefits and rewards at a nominal monthly fee.

Click here for more information or call 0861 100 789.

Condition Medicine List (CML)

This list outlines the medication covered by Profmed medical aid scheme in respect of the Chronic Disease List (CDL) conditions. It is important that your doctor or pharmacist authorises your condition and the medication by calling SwiftAuth on 0800 132 345. Benefit rules and conditions apply.

Click here to utilise the search functionality or to download the medicine list for your specific condition.

Preventative Care

As part of our commitment to your wellbeing, this benefit encourages the early detection of the most frequently diagnosed high-risk diseases. Early treatment reduces the risk of complications and is more likely to secure a better prognosis for the patient. This benefit provides cover for one consultation, pathology, radiology and vaccinations.

This benefit provides for the following vaccines:

  • Influenza
  • Human papilloma virus
  • Child immunisations
  • Pneumococcal infection.

Testing is covered for the following:

  • Breast cancer
  • Cervical cancer
  • Late onset diabetes
  • Prostate cancer
  • Cardiac disease.

Pre-authorisation is not required, except in the case of mammography for women under 40 years. The Scheme’s pathology designated service providers must be utilised to avoid co-payments.

This benefit is available to members who fall in the high-risk age categories.

Emergency Transport

Who is the Designated Service Provider

Profmed has partnered with Netcare 911 as the Designated Service Provider (DSP) to provide emergency medical assistance to members within South Africa.

In all instances where Profmed members require emergency medical transport within South Africa, it is of vital importance that the emergency number 082 911 be contacted to access such services.

Rest assured that if your circumstances warrant emergency transport, on contacting the emergency transport number, an appropriate form of transportation will be despatched to you with no capped limits, provided that services are obtained from the DSP, Netcare 911.

What your benefits include

  • Health-on-Line provides emergency telephonic medical advice and information. A qualified nursing sister will provide emergency and non-emergency telephonic medical advice to members via the 24-hour Emergency Operations Centre. Information is given in accordance with current clinical best practice.
  • Emergency medical response by road from the scene of a medical emergency.
  • Immediate response, using the most appropriate and closest ambulance resource. The ambulance and response vehicles are staffed by paramedics who can administer instant, life-saving treatment, resuscitation and stabilisation.

How to obtain assistance within South Africa

  • In emergencies where the patient is able to communicate, simply dial 082 911. The consultant receiving, the call will guide you further.
  • In an emergency where a patient is unable to communicate or make the call due to the nature of the incident and someone else calls an ambulance service other than Profmed’s provider, Netcare 911 must be informed within 48 hours of the incident. In the event where patients voluntarily utilise an ambulance service other than Profmed’s DSP, they may be responsible for a 20% co-payment on the account.

How your claims will be processed

  • Accounts submitted by the ambulance service despatched to you will be assessed by Netcare 911 and processed in accordance with the protocols of the Scheme.
  • Accounts funded personally by members must be submitted to claims@profmed.co.za for processing. However, members should preferably not pay for any accounts or ambulance services upfront as the services may not be in terms of Profmed’s protocols and could result on a co-payment due by you.

Chronic Disease List (CDL)

ProPinnacle

PRESCRIBED MINUMUM BENEFIT CDL CONDITIONS
Addison’s Disease Asthma
Bipolar Mood Disorder Bronchiectasis
Cardiac Failure Cardiomyopathy Disease
Chronic Obstructive Pulmonary Disorder Chronic Renal Disease
Coronary Artery Disease Chron’s Disease
Diabetes Insipidus Diabetes Mellitus Types 1 & 2
Dysrhythmias Epilepsy
Glaucoma Haemophilia
HIV / Aids Hyperlipidaemia
Hypertension Hypothyroidism
Multiple Sclerosis Parkinson’s Disease
Rheumatoid Arthritis Schizophrenia
Systemic Lupus Erythematosis Ulcerative Colitis
OTHER NON-CDL CONDITIONS
Allergic Rhinitis – in patients with asthma Alzheimer’s Disease
Ankylosing Spondylitis Benign Prostatic Hypertrophy
Cushing’s Syndrome Cystic Fibrosis
Deep Vein Thrombosis Gastro-oesophageal Reflux Disorder
Gout Hypoparathyroidism
Major Depressive Disorder Malabsorption Syndrome
Menopause (Calcium) Meniere’s Disease
Motor Neuron Disease Myasthenia Gravis
Obsessive Compulsive Disorders Osteoarthritis
Paget’s Disease Osteoporosis
Peripheral Vascular Disease Post-Organ Transplant (non-DTPs)
Paraplegia and Quadriplegia Psoriatic Arthritis
Pituitary Adenomas / Hyperfunction of Pituitary Gland Pulmonary Interstitial Fibrosis
Relevant Diagnostic &Treatment Pairs (DTPs) Systemic Connective Tissue Disorders
Stroke / Cerebrovascular Accident Tuberculosis
Valvular Heart Disease

Note: MMAP® and reference pricing apply on all options.
Oncology Adjunctive Treatment is now paid from Scheme risk.

ProSecure Plus

PRESCRIBED MINUMUM BENEFIT CDL CONDITIONS
Addison’s Disease Asthma
Bipolar Mood Disorder Bronchiectasis
Cardiac Failure Cardiomyopathy Disease
Chronic Obstructive Pulmonary Disorder Chronic Renal Disease
Coronary Artery Disease Chron’s Disease
Diabetes Insipidus Diabetes Mellitus Types 1 & 2
Dysrhythmias Epilepsy
Glaucoma Haemophilia
HIV / Aids Hyperlipidaemia
Hypertension Hypothyroidism
Multiple Sclerosis Parkinson’s Disease
Rheumatoid Arthritis Schizophrenia
Systemic Lupus Erythematosis Ulcerative Colitis
OTHER NON-CDL CONDITIONS
Allergic Rhinitus (in patients with asthma) Alzheimer’s Disease
Ankylosing Spondylitis Benign Prostatic Hypertrophy
Major Depressive Disorder Obsessive Compulsive Disorders
Osteoporosis Paraplegia and Quadriplegia
Pituitary Adenomas / Hyperfunction of Pituitary Gland Pulmonary Interstitial Fibrosis
Psoriatic Arthritis Relevant Diagnostic & Treatment Pairs (DTPs)
Valvular Heart Disease

Note: MMAP® and reference pricing apply on all options.
Oncology Adjunctive Treatment is now paid from Scheme risk.

ProSecure

PRESCRIBED MINUMUM BENEFIT CDL CONDITIONS
Addison’s Disease Asthma
Bipolar Mood Disorder Bronchiectasis
Cardiac Failure Cardiomyopathy Disease
Chronic Obstructive Pulmonary Disorder Chronic Renal Disease
Coronary Artery Disease Chron’s Disease
Diabetes Insipidus Diabetes Mellitus Types 1 & 2
Dysrhythmias Epilepsy
Glaucoma Haemophilia
HIV / Aids Hyperlipidaemia
Hypertension Hypothyroidism
Multiple Sclerosis Parkinson’s Disease
Rheumatoid Arthritis Schizophrenia
Systemic Lupus Erythematosis Ulcerative Colitis
OTHER NON-CDL CONDITIONS
Allergic Rhinitus (in patients with asthma) Alzheimer’s Disease
Ankylosing Spondylitis Benign Prostatic Hypertrophy
Major Depressive Disorder Obsessive Compulsive Disorders
Osteoporosis Paraplegia and Quadriplegia
Pituitary Adenomas / Hyperfunction of Pituitary Gland Psoriatic Arthritis
Pulmonary Interstitial Fibrosis Relevant Diagnostic & Treatment Pairs (DTPs)
Valvular Heart Disease

Note: MMAP® and reference pricing apply on all options.
Oncology Adjunctive Treatment is now paid from Scheme risk.

ProActive Plus

PRESCRIBED MINUMUM BENEFIT CDL CONDITIONS
Addison’s Disease Asthma
Bipolar Mood Disorder Bronchiectasis
Cardiac Failure Cardiomyopathy Disease
Chronic Obstructive Pulmonary Disorder Chronic Renal Disease
Coronary Artery Disease Chron’s Disease
Diabetes Insipidus Diabetes Mellitus Types 1 & 2
Dysrhythmias Epilepsy
Glaucoma Haemophilia
HIV / Aids Hyperlipidaemia
Hypertension Hypothyroidism
Multiple Sclerosis Parkinson’s Disease
Rheumatoid Arthritis Schizophrenia
Systemic Lupus Erythematosis Ulcerative Colitis
OTHER NON-CDL CONDITIONS
Relevant Diagnostic & Treatment Pairs (DTPs)

Note: MMAP® and reference pricing apply on all options.
Oncology Adjunctive Treatment is now paid from Scheme risk.

ProActive

PRESCRIBED MINUMUM BENEFIT CDL CONDITIONS
Addison’s Disease Asthma
Bipolar Mood Disorder Bronchiectasis
Cardiac Failure Cardiomyopathy Disease
Chronic Obstructive Pulmonary Disorder Chronic Renal Disease
Coronary Artery Disease Chron’s Disease
Diabetes Insipidus Diabetes Mellitus Types 1 & 2
Dysrhythmias Epilepsy
Glaucoma Haemophilia
HIV / Aids Hyperlipidaemia
Hypertension Hypothyroidism
Multiple Sclerosis Parkinson’s Disease
Rheumatoid Arthritis Schizophrenia
Systemic Lupus Erythematosis Ulcerative Colitis
OTHER NON-CDL CONDITIONS
Relevant Diagnostic & Treatment Pairs (DTPs)

Note: MMAP® and reference pricing apply on all options.
Oncology Adjunctive Treatment is now paid from Scheme risk.

Trauma and HIV Assistance Programme

 

This programme provides members with 24-hour access to trauma counselling and/or HIV assistance in the event of a trauma, e.g. rape, hijacking, needle-stick injury or any traumatic life-changing event.

In the event that you are a victim of crime, you and your dependants will be entitled to immediate and follow-up trauma counselling. All counselling, whether telephonic or face-to-face consultations, are undertaken by registered psychologists. Where relevant, victims will be accompanied by an appropriate, qualified professional to identity parades and court appearances for emotional support.

The number to call is 0861 776 363. All calls and treatments are dealt with in the strictest confidence. You will be assigned a case manager, who will ensure you receive the correct treatment, whether it be counselling, post-HIV exposure treatment or both.

The Trauma and HIV Assistance Programme provides:

24-hour assistance

Appropriate number of telephonic counselling sessions as determined by case manager

Up to four sessions per incident for face-to-face counselling

Immediate access to HIV exposure prophylaxis

Initial and follow-up HIV testing

3-6 months’ HIV exposure management

Subject to use of the DSPN

This benefit is available on all options at no cost to members and benefits are paid from risk, provided services are obtained from Lifesense, the DSP. Services obtained from a non-DSP will be subject to co-payments and the protocols of the DSP. This programme is not available to members residing in the SADC region. However, these members may access counselling or HIV exposure medication cover from the relevant day-to-day benefits available to them on the option they are on.

Emergencies with the SADC region

Emergency assistance requests from countries within the SADC region.

SADC region refers to a group of countries in southern Africa, i.e. Angola, Botswana, Democratic Republic of Congo, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, Tanzania (including Zanzibar), Zambia and Zimbabwe.

From within the SADC region, please call +27 11 541 1225 for emergency medical assistance. If the circumstances permit, International SOS will arrange for a suitable, appropriate local emergency transport organisation to assist you or you will be referred to a local suitably equipped medical facility. If suitable facilities are not available where you are situated, appropriate emergency transport will be despatched to evacuate you to the closest most appropriate facility.

International Travel Medical Assistance

  • Members on all options are covered up to R6 million per beneficiary per journey for a travel period of not longer than 90 days.
  • Members are no longer required to activate cover prior to departure
  • If required, embassy letters for the purpose of applying for visas can be requested from the Profmed app, or obtained from Client Services
  • Proof of travel to be submitted when claiming

Click here for more information.

Contraceptives

This benefit is subject to a benefit limit per beneficiary and is paid from risk, at 100% Single Exit Price and dispensing fee at DSPN rate. MMAP® applies. Subject to annual sub-limit. This benefit covers oral contraceptives and patches, the injection, implants and intra-uterine devices. Oral contraceptives used for any other purpose than contraception will not be funded.