2013
P R O FMED B EN E F I T S AT A GL A NCE
The Schedule of Benefits containing full details of the benefits, limits
and exclusions that apply is available at www.profmed.co.za
or by calling 0800 334 733.
Introducing Profmed
Profmed is the largest restricted medical scheme in South Africa uniquely designed for graduate professionals. Although registered
in 1969, Profmed has been providing benefits since 1959, making it one of the longest established medical schemes in South Africa.
Profmed serves over 26 700 discerning members, providing 62 800 lives with exceptional medical benefits.
Profmed offers:
• Quality medical cover tailored to suit the lifestyle of professionals
• Rich maternity benefits with lenient underwriting on pregnancy
• Multiply Wellness Programme (optional)
• Rich oncology cover on all options
• No deposits required for hospital admissions
• Private wards offered on selected options
• Rates for students that are the lowest in the industry
• Financially stable solvency levels in excess of statutory requirements
• 2012 GCR rating upgraded to AA- (Double A minus).
Who qualifies?
If you’re a graduate professional with a 4-year or post-graduate university degree, or if you’re in at least your fourth academic year of
study for a degree that will qualify you to provide a professional service, you are eligible for Profmed*.
Benefit options
Profmed’s range of options enables you to select medical cover to suit your lifestyle.
ProPinnacle
ProSecure Plus
ProSecure
ProActive Plus
ProActive
Comprehensive
hospital and
day-to-day cover
for complete
peace of mind
Hospital and
day-to-day
benefits for the
growing family
Hospital and
day-to-day
benefits for the
younger family
Hospital benefits
for young
professionals
Hospital benefits
for students
and young
professionals
Benefit structure
Profmed is a traditional medical scheme. The diagram below illustrates the difference between a traditional and new generation
medical scheme.
New generation
Savings account
(up to 40% of
contributions)
Day-to-day
benefit
(limited to 25% of
contributions)
In-hospital cover
Self-payment gap
Threshold benefit
In-hospital cover
A traditional medical scheme is uncomplicated, offering
more certainty on the benefits, as the limits are clearly
defined. This clarity provides greater peace of mind and
understanding of the benefits.
* Qualifying criteria apply. Call 0800 334 733 for more information.
Day-to-day benefit
Traditional
In a new generation medical scheme, a portion of the
premium goes towards hospital cover and, in some
instances, a threshold benefit, while the remaining portion is
allocated to a ‘savings account’. Out-of-hospital claims are
paid from the savings account, which has a threshold limit.
In this structure there may be a self-payment gap between
the savings and threshold limit. The complexity of the new
generation structure leaves the member uncertain of the
scope and extent of medical cover to which they are entitled.
Benefit options at a glance
Monthly contribution
ProPinnacle
Adult: R4 040
Adult dependant: R3 748
Child: R1 010
Risk benefits
• Hospitalisation
›› doctors paid at Profmed Premium Tariff*
›› private wards
• Preventative care from designated
service providers
• Oral contraceptives
• Chronic medication
›› cover for 58 chronic conditions plus
relevant DTPs
›› no benefit limit
Day-to-day benefits
• Out-of-hospital MRI & CT scans
›› 80% benefit, paid from risk
• Trauma and HIV assistance from
designated service provider
• International travel medical assistance
›› R3 million per beneficiary per journey
›› R1 000 excess on out-of-hospital expenses
•
•
•
•
•
•
•
Doctors’ consultations
Acute medication
Over-the-counter medication
Radiology & pathology
Optical
Dentistry
Maternity
›› hospitalisation in private wards, both
ante-natal and post-delivery
Optional
• Multiply Wellness Programme
ProSecure Plus
Monthly contribution
Adult: R2 412
Adult dependant: R2 232
Child: R940
Monthly contribution
ProSecure
Adult: R1 964
Adult dependant: R1 818
Child: R766
Risk benefits
Risk benefits
• Hospitalisation
›› doctors paid at Profmed Plus Tariff ‡
• Preventative care from designated service providers
• Oral contraceptives
• Chronic medication
›› cover for 38 chronic conditions plus relevant DTPs
›› benefit limit applies
• Trauma and HIV assistance from designated service provider
• International travel medical assistance
›› R3 million per beneficiary per journey
›› R1 000 excess on out-of-hospital expenses
• Hospitalisation
›› doctors paid at Profmed Specific Tariff**
• Preventative care from designated service providers
• Oral contraceptives
• Chronic medication
›› cover for 38 chronic conditions plus relevant DTPs
›› benefit limit applies
• Trauma and HIV assistance from designated service provider
• International travel medical assistance
›› R3 million per beneficiary per journey
›› R1 000 excess on out-of-hospital expenses
Day-to-day benefits
Day-to-day benefits
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Doctors’ consultations
Acute medication
Over-the-counter medication
Radiology & pathology, including MRI & CT scans
Optical
Dentistry
Maternity
›› hospitalisation post-delivery in private wards
Optional
Optional
• Multiply Wellness Programme
• Multiply Wellness Programme
ProActive Plus
Doctors’ consultations
Acute medication
Over-the-counter medication
Radiology & pathology, including MRI & CT scans
Optical
Dentistry
Maternity
Monthly contribution
Adult: R1 128
Adult dependant: R1 048
Child: R440
Monthly contribution
ProActive
Adult: R 1 002
Adult dependant: R 926
Child: R 390
Risk benefits
Risk benefits
• Hospitalisation
›› doctors paid at Profmed Plus Tariff ‡
›› in-hospital dentistry (exceptional cases only)
• Preventative care from designated service providers
• Oral contraceptives
• Chronic medication
›› restricted to 26 chronic conditions plus relevant DTPs
›› per formulary and algorithm
• Trauma and HIV assistance from designated service provider
• Maternity hospitalisation
• International travel medical assistance
›› R3 million per beneficiary per journey
›› out-of-hospital expenses not covered
• Hospitalisation
›› doctors paid at Profmed Specific Tariff**
›› in-hospital dentistry (exceptional cases only)
• Preventative care from designated service providers
• Oral contraceptives
• Chronic medication
›› restricted to 26 chronic conditions plus relevant DTPs
›› per formulary and algorithm
• Trauma and HIV assistance from designated service provider
• Maternity hospitalisation
• International travel medical assistance
›› R3 million per beneficiary per journey
›› out-of-hospital expenses not covered
Optional
Optional
• Multiply Wellness Programme
• Multiply Wellness Programme
* Profmed Premium Tariff
The maximum tariff paid by the Scheme – 300% of Profmed Tariff
‡ Profmed Plus Tariff
200% of Profmed Tariff
**Profmed Specific Tariff
Procedures: Profmed Tariff plus 20%
Consultations: R330 for GPs and R420 for specialists
Chronic medication
Table 1
Prescribed Minimum Benefit CDL* Conditions
1.
2.
3.
4.
5.
6.
7.
8.
9.
Addison’s Disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac Failure
Cardiomyopathy Disease
Chronic Obstructive Pulmonary Disorder
Chronic Renal Disease
Coronary Artery Disease
10.
11.
12.
13.
14.
15.
16.
17.
18.
Available on all options
Crohn’s Disease
Diabetes Insipidus
Diabetes Mellitus Type 1 & 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia
HIV/AIDS
Hyperlipidaemia
Table 2
Other non-CDL* Conditions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Allergic Rhinitis – in patients with asthma
Alzheimer’s Disease
Ankylosing Spondylitis
Benign Prostatic Hypertrophy
Cushing’s Disease
Cystic Fibrosis
Deep Vein Thrombosis
Gastro-oesophageal Reflux Disorder
Gout
Hypoparathyroidism
Hyperthyroidism
Alzheimer’s Disease
Ankylosing Spondylitis
Benign Prostatic Hypertrophy
Major Depressive Disorder
Obsessive Compulsive Disorders
Oncology Adjunctive Treatment
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinson’s Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus Erythematosus
Ulcerative Colitis
Available ONLY on ProPinnacle option
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Major Depressive Disorder
Malabsorption Syndrome
Meniere’s Disease
Motor Neuron Disease
Myasthenia Gravis
Obsessive Compulsive Disorders
Oncology Adjunctive Treatment
Osteoarthritis
Osteoporosis
Paget’s Disease
Paraplegia & Quadriplegia
Table 3
Other non-CDL* Conditions
1.
2.
3.
4.
5.
6.
19.
20.
21.
22.
23.
24.
25.
26.
23. Peripheral Vascular Disease
24. Pituitary Adenomas/Hyperfunction
of Pituitary Gland
25. Psoriatic Arthritis
26. Pulmonary Interstitial Fibrosis
27. Stroke/Cerebrovascular Accident
28. Systemic Connective Tissue Disorders
29. Tuberculosis
30. Valvular Heart Disease
31. Relevant Diagnostic & Treatment
Pairs (DTPs)**
Available ONLY on ProSecure Plus
and ProSecure options
7.
8.
9.
Osteoporosis
Paraplegia & Quadriplegia
Pituitary Adenomas/Hyperfunction
of Pituitary Gland
10. Psoriatic Arthritis
11. Pulmonary Interstitial Fibrosis
* Chronic Disease List
**Covered on the ProActive Plus and ProActive options
12. Valvular Heart Disease
13. Relevant Diagnostic & Treatment
Pairs (DTPs)**
Note: MMAP® and reference pricing apply on all options
Supplementary information
Hospitalisation
Trauma and HIV Assistance Programme
•
•
•
•
•
•
•
• Covers trauma and HIV exposure resulting from crime,
e.g. assault or rape
• Covers HIV exposure resulting from occupational injuries,
e.g. needle-stick injury
• 24-hour assistance at dedicated call centre
• Appropriate number of telephonic and face-to-face
counselling sessions as determined by case manager
• Immediate access to HIV exposure prophylaxis
• Initial and follow-up HIV testing
• 3 - 6 months HIV exposure management
• Subject to the use of the DSPN
Unlimited cover on all options
Cover in any registered hospital
Rich oncology benefit
Full dread disease cover
Unlimited peritoneal dialysis and haemodialysis
No deposits required on admission to hospital
Maternity benefits
›› ante-natal in-patient hospitalisation
›› delivery fee – GP, specialist or registered midwife
›› labour and ward accommodation
›› neonatal care
Preventative Care
Sabbatical Benefit
• Early detection of high-risk diseases
• Testing for breast cancer, prostate cancer, cervical
cancer, cardiac disease and late onset diabetes
• Facilitates early treatment to maximise positive outcome
• Influenza vaccine
• Human papillomavirus (HPV) vaccine
• Sabbatical includes overseas travel, contract
work or furthering of studies
• No underwriting for members who return from sabbatical
• Sabbatical period limited to three years
• Available only after at least one year of Profmed membership
International Travel Medical Assistance
Multiply Wellness Programme (optional)
• Cover limited to journeys not exceeding 90 days each
• South African residents covered while travelling across the borders
of South Africa
• SADC Region residents covered while travelling across the borders
of their country of residence, except in South Africa where normal
benefits apply
• Optional buy-up cover available for loss of baggage, inconvenience
cover, etc., from ACE Insurance
• Cover not available for conditions in a condition-specific waiting
period and during a general waiting period
• Base Multiply available to all members, at no cost
• Discounts and special packages on selected health and lifestyle products
• Free Flexibreaks membership for holiday and
accommodation deals on Base and full Multiply
• Informative newsletter and online nutritional advice and tips
• Full Multiply package available at a monthly fee
• Additional benefits on full Multiply, including discounts
on gym fees, airfares and movie tickets
• “Momentous Baby Programme” offering on full Multiply
• Additional broker commission earnings
Oral Contraceptives
• Contraceptive purposes only
• Available on all options
Note: Protocols and clinical management apply
Which option to choose
I am a student…
I only need hospital cover
Consider ProActive
(reduced rates apply for students)
I only need…
cover for planned or emergency
hospital admissions
Consider ProActive or ProActive Plus
I need…
cover for planned or emergency hospital
admissions as well as day-to-day benefits
Consider ProSecure, ProSecure Plus
or ProPinnacle
I need…
benefits for one of the listed chronic
conditions and my chronic medication
costs less than R1 000 per month
Consider ProSecure or ProSecure Plus
(cover for 38 chronic conditions plus
relevant DTPs, with benefit limits)
I need…
a private ward when hospitalised and
benefits for one of the listed chronic
conditions and my chronic medication
costs more than R1 000 per month
Consider ProPinnacle
(cover for 58 chronic conditions plus
relevant DTPs, with no benefit limit)
The above suggestions are guidelines, but you may belong to any option of your choice.
Intermediary support and other important contact numbers
Intermediaries
Client claims information, product information and commission
www.profmed.co.za
[email protected]
Intermediary support: 0860 679 200
Information to assist your client
www.profmed.co.za
Receive an instant report on last 20 claims by sending a blank e-mail,
from an e-mail address registered on the system, to:
[email protected]
How to join Profmed
Call: 0800 DEGREE (334 733)
E-mail: [email protected]
Client Services
0860 679 200
[email protected]
Private Bag X1031, Lyttelton, 0140
Walk-in centres
Block D, Corporate Office Park 66,
Cnr Von Willigh and Lenchen Avenues,
Die Hoewes, Centurion
and
6 Anerley Road, Parktown, Johannesburg
Disclaimer: In the event of a conflict between this brochure and the registered rules of the Scheme, the rules will prevail.
E&OE. Copyright 2012. 09/2012.
Profmed is an authorised Financial Services Provider – FSP 43918