Profmed ProPinnacle Premium medical aid plan: 2020

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View all plans in this scheme.
Always consult with your broker before making final decisions regarding your healthcare cover.

Benefits outlined:

ProPinnacle Premium
Total Cost pm:

Main member:

R8,178

Adult:

R7,586

Child:

R2,453
Savings (per year):
  • No savings option on this plan
Extended Fund:RM =R18,281
M+ =R27,077
Max per family: R35,190
RR
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IN HOSPITAL PROCEDURES:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
non-Network Specialists:
  • 300% scheme tariff
network Specialists:
  • n/a
non-Network GPs:
  • 300% scheme tariff
network GPs:
  • n/a
Hospital Choice:
  • Any hospital
Penalty for using other hospital:
  • n/a
  • n/a
Specialised Radiology:
  • MRI and CT scans: 2 scans per family
Supplementary Services: (Physio, etc)
  • 100% scheme tariff
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • 100% scheme rate
Co-payments:
Alternatives to hospitals:
  • Rehabilitation: R80,779 per family
  • Outpatient care in lieu of hospitalisation: R17,459 per person
  • Wound care: R6,740 per person
Casualty:
  • Both the Blue Plan and Red Plan gap cover will pay up to R10,000 per person for unpaid casualty costs in event of emergency
Other:
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R165,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R165,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover "penalties" (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)
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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL PROCEDURES:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
Summary:
Main Member:Adult:Child:
Savings /yr:No savings option on this plan
Extended Fund:RM =R18,281
M+ =R27,077
Max per family: R35,190
RR
General info:
  • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
GP consultations:
  • See Primary Health Care benefit above
Childcare:
Specialists consultations:
  • See Primary Health Care benefit above
Pathology:
  • See Primary Health Care benefit above
General radiology:
  • See Primary Health Care benefit above
Specialised radiology:
Supplementary Services: (Physio, etc)
  • Physiotherapy, post-operative: R3,086 per person and R5,142 per family
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MATERNITY BENEFITS:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
Hospital stay:
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
Scans:
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CANCER (ONCOLOGY):
ProPinnacle Premium
Scheme Benefits:Notes and Links:
Overall coverage (in and out of hospital):
  • R685,523 per person
  • Specialised drugs: 80% of Single Exit Price, plus dispensing fee. Subject to above limit
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DENTISTRY:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
Standard Dentistry:
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Specialised Dentistry:
In-Hospital Dentistry:
Orthodontics:
Maxillo Facial Surgery:
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MEDICATION:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
Chronic:
Acute (presrcibed) medication:
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Over-the-counter:
Birth Control:
On Discharge:
Biological:
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OPTOMETRY:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
Optometry:
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
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MENTAL HEALTH:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
In-hospital:
  • R40,445 per family
Out-of-hospital:
  • R6,855 per family, and subject to in-hospital limit
Trauma:
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OTHER BENEFITS:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
General Appliances:
1.1. Hearing Aids:
1.2. Wheelchairs:
Dialysis:
International Insurance:
Other:
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WELLNESS/ PREVENTATIVE BENEFITS:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
Flu vaccination:
Pneumonia vaccines:
Biometric Screening:
Child Immunisation:
Pap Smear:
Mammogram:
PAS Test:
HIV Test:
Other:
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PROSTHETICS:
ProPinnacle Premium
Scheme Benefits:Notes and Links:
Overal Limit:
  • Internal: R52,557 per family
  • Intraocular lens: R4,971 per person, per event
Sub-limits:
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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • "Unlimited" benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised

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