Assume scheme pays all these costs, unless otherwise stated
non-Network Specialists:
175% scheme rate
Scheme rate is set by Profmed
network Specialists:
175% scheme rate
non-Network GPs:
175% scheme rate
network GPs:
175% scheme rate
Hospital Choice:
Any hospital
Day Hospitals:
Specified day procedures: Day Procedure Network, or R5,000 co-payment
Penalty for using other hospital:
Use of non-Day Procedure Network: R5,000 co-payment
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
* There might be other co-payments if you don't use scheme-chosen provider for some services.
* Treatment required for PMB level care is always paid by scheme, with no co-payment, if you follow the protocols. That means that these co-payments might not apply in your case! More info here
Specialised Radiology:
MRI, radio-isotope and CT scans: 2 scans per family
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
175% scheme rate
No limits or co-payments for PMB level care and/or for emergency
Transplants:
100% scheme rate
Dialysis:
100% scheme rate
Exclusions:
* Treatment required for PMB level of care is always paid by scheme, if you follow the protocols. It cannot be excluded. More info here.
* All schemes have extensive exclusions. We've tried to list the major ones here, but please consult your scheme or broker to get the full list
All medical aids must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
This can include consults with specialists, blood or other tests, radiology and medicine
The benefit is paid by the scheme, and not out of your savings account
If you have no day-to-day funds, you still have cover for PMBs
Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
M= R718
M1= R1,027
Maximum R1,335 per family
From day-to-day benefit, at 80% cost
Over-the-counter:
From acute medcicine benefit
Birth Control:
Oral, patches, injections, implants
and intra-uterine devices: R1,962 per person, not from day-to-day benefit
On Discharge:
7 days supply at 80% scheme rate, from Acute Medicine benefit
Biological:
PMBs only
Treatment that is required (by law) for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here.)
Note:
Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
