Additional Information on Benefits
Peace of mind when you need it most
We provide intelligent benefits to discerning members. Over and above the evidence-based and clinically appropriate treatment our members enjoy, we provide additional assistance and programmes designed to support your health and wellness needs, whether you’re at home or travelling overseas. These additional benefits are available on all ten of Profmed’s medical aid benefit options.
The chronic medication covered by the Scheme forms part of the legislated 270 PMB medical conditions. The Chronic Medication benefit provides cover for the medication required to treat chronic conditions. The consultations and procedures (DTPs) related to these conditions are paid from the available day-to-day benefit. DTPs are the Diagnostic and Treatment Pairs required to diagnose and manage chronic conditions.
Chronic medication is medication used for more than a month for the 26 Chronic Disease List (CDL) conditions available on all options and the additional conditions listed for each option in the Schedule of Benefits.
Your doctor or pharmacist must authorise your condition as clinical data and information must be provided to accurately classify the condition. No forms need to be completed. Your doctor or pharmacist must call Chronic Authorisations on 0800 132 345.
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This benefit covers oral contraceptives and patches, the injection, implants and intra-uterine devices. Oral contraceptives used for any purpose other than contraception will not be funded. This benefit is available on all options, subject to a benefit limit per beneficiary, and is paid from risk.
Members residing within the SADC Region, other than Namibia, are only entitled to benefits for medical services received within South Africa. Any treatment or medication obtained within the country of residence in the SADC Region will not be covered by Profmed. Members who require guidance or advice in respect of medical assistance may contact International SOS on +27 11 541 1225 but any costs resulting from this are for the member’s private account.
Members who travel outside their country of residence in the SADC Region have access to the International Travel Medical Assistance benefit by calling International SOS.
Countries in the SADC Region are Angola, Botswana, Comores, Democratic Republic of Congo, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, Tanzania (including Zanzibar), Zambia and Zimbabwe.
Namibian members
Profmed does not have relationships with emergency transport providers outside South Africa. Therefore, members living in Namibia must contact International SOS on +27 11 541 1225 should they require emergency medical assistance or transportation within Namibia. However, should that call-out result in admission to hospital in Namibia, authorisation must be obtained directly from Profmed and not through International SOS.
Admissions on weekends, after working hours or on public holidays must be authorised on the next working day. If the member is incapable of fulfilling this requirement, it is the responsibility of the hospital to obtain authorisation.
The number to call for pre-authorisation from outside RSA is +27 12 679 4145.
Profmed has partnered with Netcare 911 to provide emergency medical assistance to members within South Africa. The number to call is 082 911.
Rest assured that if your circumstances warrant emergency transport, an appropriate form of transportation will be dispatched to you with no capped limits, provided that services are obtained through Netcare 911, Profmed’s designated service provider.
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Hospitalisation refers to admission for treatment or a procedure that can only be undertaken in-hospital. Hospitalisation for the sole purpose of undergoing radiology or pathology investigations will not be funded. Deposits are not required on admission to hospital. Members on the Savvy options are required to make use of hospitals on the Savvy hospital network. A co-payment applies for voluntary use of a non-network hospital on the Savvy options.
Cover for hospitalisation includes the cost of hospital facilities, such as ward fees and theatre fees, as well as materials and medicines (excluding medicine taken home on discharge). These fees are controlled either by legislation, in the case of medicine, or negotiation between Profmed and the various hospitals and hospital groups. Hospitalisation costs do not include the fees charged by the treating doctor and other healthcare practitioners.
Before a beneficiary can be admitted to hospital for an elective procedure, it is the member’s responsibility to obtain pre-authorisation at least 7 days prior to the hospital event by calling Pre-authorisations on 0861 776 363.
Click here for more information on pre-authorisation.
This benefit is available to members who are travelling for not longer than 90 days from date of departure. You do not need to activate cover prior to departure. International SOS is Profmed’s designated service provider for international medical assistance. Before accessing medical treatment, please call +27 11 541 1225. Out-of-hospital treatment must be paid up-front and a R10 000 benefit limit that is subject to the overall limits below. A R2 000 co-payment applies.
For the purpose of applying for visas, members travelling overseas can request an embassy letter on the Profmed App.
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| ProPinnacle and ProPinnacle Savvy | R8 million |
| ProSecure Plus, ProSecure Plus Savvy, ProSecure, and ProSecure Savvy | R5 million |
| ProActive Plus, ProActive Plus Savvy, ProActive and ProActive Savvy | R2.5 million |
Tums2Tots Baby Programme will provide you with support to make your pregnancy an enjoyable journey. Once you’ve registered on the programme, you will receive a gift of your choice, updates on the stages of your pregnancy every trimester and you can connect and share information and ideas with other moms.
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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 patients. This benefit also provides cover for vaccinations to prevent the onset of disease.
Pre-authorisation is not required. In the case of mammography, women under 40 years who are pre-disposed to breast cancer my access this benefit subject to motivation. The Scheme’s pathology designated service providers must be utilised to avoid co-payments.
The relevant tariff codes as provided in the Schedule of Benefits must reflect on preventative care claims to ensure claims are paid from the correct benefit.
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This programme provides members with 24-hour access to trauma counselling and HIV assistance in the event of a trauma, such as rape, hijacking, needle-stick injury or any traumatic life-changing event. This benefit is not subject to the day-to-day limit and is available on all options.
If you require assistance, call 0861 776 363. All calls and treatment are dealt with in the strictest confidence. You will be assigned a case manager, who will ensure you receive the correct treatment.
PPS Wallet is an independent savings account that works seamlessly for the payment of healthcare expenses. It’s available to all Profmed members across all Scheme options.
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Profmed recognises the impact of Gender Based Violence, particularly when the violence or abuse is perpetrated by someone close to you. Our new WHISPA programme provides a safe place for victims of all ages and genders to voice their fear and trauma and to access professional counselling and legal assistance.
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Profmed provides unlimited benefits for hospitalisation, but the tariffs charged by some surgeons, anaesthetists and other specialists may be higher than the tariffs covered by Profmed.
This results in shortfalls that can be costly.
Medical expense shortfalls can range from R37 000 for a Caesarean Section childbirth up to R100 000 for shoulder surgery, cancer treatment and heart surgery.
Click here to learn more.
