Profmed medical aid scheme aims to make the claims procedure as user-friendly as possible for its members. In most cases claims are submitted electronically by the service provider, i.e. your doctor, dentist, pharmacist, etc. However, you must check all claims submitted on your behalf to ensure that the service has indeed been rendered to you.
Pre-authorisation is based on clinical criteria, not on the availability of benefits and is not a guarantee of payment. Benefits are funded subject to the benefit limits and availability of funds at the time the claim is received by the Scheme for processing, and in accordance with the relevant protocols and Scheme rules.
The Prescribed Minimum Benefits (PMBs) covered by Profmed medical aid scheme are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of any emergency medical condition.
The reference price is a limit to the financial benefit available for your medication (drug). If the cost of the drug that you are using is greater than the applicable reference price, then you will be required to pay the difference between the cost of your drug and the reference price at the point of sale.
Profmed's philosophy is to provide quality, comprehensive healthcare while maintaining affordable contributions. In order to strike the necessary balance to achieve our philosophy, it is necessary to introduce DSPNs.