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nThe Pinnacle Efficiency Discounted option 2015You can look forward to exceptional value and benefits for 2015.

Netcare You’re in safe hands Dis-chem Pharmacists who care

Day-to-day benefits

The PinnacleEfficiency

Discounted (ED) option

The Pinnacle ED option offers comprehensive cover for the

discerning achiever, at a Netcare hospital and superior day-

to-day benefits comprising a combination of savings account, traditional risk

cover and very competitive above threshold benefits. Chronic medicine must be obtained from DSP

(Dischem).

Step 1Day-to-day healthcare claims are initially paid from the annual Medical Savings Account (MSA). The annual MSA funds are advanced to members at the beginning of the year. If you resign from the medical Scheme during the year, you may be liable for a pro-rata usage portion of the MSA advance.

Step 2Once the annual MSA is depleted, day-to-day healthcare claims are paid from the AFB. The AFB is a risk benefit, meaning that the “Scheme” pays for it.

Step 3When the MSA and AFB is depleted, you enter into a SPG. The SPG can be seen as an excess before the medical aid pays your claim again. Once your annual MSA and AFB are depleted, you are responsible to pay your own claims. (Self Payment Gap (SPG)).

Whilst in your SPG, again you must still submit these claims to CompCare Wellness for processing. This is a very important step in the claiming process as these claims accumulate to the Threshold level.

Step 4Once you reach the TL, you have access to above threshold benefits (ATB)

Step 5In the ATB you have additional day-to-day benefits with certain sub-limits. These benefits include specialists, medication (chronic and acute), radiology and pathology.

See contribution table for values of MSA, AFB, SPG and TL.

Understanding your day-to-day benefits in 5 easy steps

Above Threshold Benefit (ATB)Claims are now paid from the above threshold benefit.

Sub-limits apply

Threshold Level (TL)When you reach your threshold (claims accumulate to

threshold) your above threshold benefit kicks in

Self Payment Benefit (SPG)Once your MSA and AFB have been depleted, you need to pay your healthcare expenses from your own pocket –

keep on submitting these claims, as they accumulateto threshold

Annual Flexi Benefit (AFB)Once MSA is depleted, claims are paid from

your annual AFB

Medical Savings Account (MSA)Claims are initially paid from your annual MSA

1

1. Make use of a Universal Network Provider for GP, Dental or Optometry benefit

2. Use a Universal Network Provider to refer you to a specialist

3. Earn money through certain wellness activities

NEW!This is how you can earn 20% towards your day-to-day benefits:

2Day-to-day benefits

Your day-to-day benefits and limits

BenefitClaims initially paid from MSA and AFB

Claims accumulate to the Threshold

Level

Benefits payable from the Above Threshold Level

Above Threshold benefit – Annual limit R7 525 p/b

and R15 135 p/f, sub-limits per benefit categories

Claims paid from Risk (not subject to the MSA and AFB)

Limits

General Practitioners UnlimitedPaid at 100% of AT. If you use a GP in the Universal Network, you will earn 10% of the claims amount into your AFB++ Account

Specialist consultationsR3 785 per family, subject to overall above threshold limit

Paid at 200% of AT, accumulation at 100% of AT. To earn 10% additional AFB, get a referral from a Universal Network GP

Acute medicationR3 150 per family, subject to overall above threshold limit

Reference pricing applies

Over-the-counter medication (OTC)Limited to one script per day and a maximum of R180 per event. Annual limit R840 p/b and R1 190 p/f

Chronic medication26 CDL’s. Must be obtained from Dischem

Unlimited for registered CDL conditions. reference pricing applies

Chronic medication46 non-CDL’s. Medicine must be obtained from Dischem

R3 785 per family, subject to overall above threshold limit

Limited to R10 090 p/b and R15 150 p/f. Reference pricing applies

Basic radiology including black and white X-rays and ultrasound

R3 785 per family, subject to overall above threshold limit, combined with pathology

Paid at 100% AT

Specialised radiology including MRI/CT and PET scans. (Combined in-and out-of-hospital benefit)

R2 250Paid at 100% AT. UnlimitedThe first R2 250 is payable from the MSA and AFB with accumulation to threshold. Pre-authorisation required

Basic pathologyR3 785 per family, subject to overall above threshold limit, combined with radiology

Paid at 100% AT

Basic dentistry UnlimitedPaid at 100% AT. Unlimited above threshold. Utilisation of a Universal Network Provider will earn you 10% of the payment amount into your AFB++ account

Specialised dentistry, including maxillo-facial and oral surgery (in-and-out of hospital limits applies)

Paid at 100% AT, limited to R14 575 p/b, same limit applies to the accumulation to threshold

Optical including: optical consultation contact lenses, frame

Paid at 100% SAOA, 2 optical consultations p/b. Lenses and frames limited to R3 785 p/b, frame sub-limit of R1 910 p/b. Utilisation of a Universal Network Provider will earn you 10% of the payment amount into your AFB++ account

Auxiliary services including:Audiologists, chiropractors, dieticians, homeopathic consultations, naturopathic consultations, speech and occupational therapists, chiropody/podiatry, social workers, physiotherapy and biokinetics

Only physiotherapy and biokinetics are payable from the above threshold benefit and is limited to R2 530 p/f, subject to the overall above threshold limit

Paid at 100% AT, limited to R6 295 p/f

Clinical psychologists Limited to R4 155 p/f

Psychiatry Limited to R13 885 p/f

Day-to-day benefits3Your day-to-day benefits and limits

BenefitClaims initially paid from MSA

and AFB

Claims accumulate to the Threshold

Level

Benefits payable from the Above Threshold Level

Above Threshold benefit – Annual limit R7 525 p/b

and R15 135 p/f, sub-limits

per benefit categories

Claims paid from Risk (not subject to the MSA and

AFB)

Limits

Surgical and medical appliances including:Wheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixators

100% of cost. Limited to R56 180 p/f, sub-limits apply

Oxygen home ventilation Subject to pre-authorisation, PMB’s and protocols

Private nursing at homeSubject to pre-authorisation and protocols. In lieu of hospitalisation (excludes post partum cases)

Ante-natal classes 100% AT. Limited to R1 070

Ambulance services 100% of cost, unlimited. Preferred provider

Hospital emergency not requiring admission Subject to PMB’s. Excludes facility fees

Hospital emergency as a result of a physical injury caused by an external force

100% ATSubject to PMB’s and protocols

4Wellness benefits

BenefitClaims paid from

Risk (not subject to the MSA and AFB)

Limits

Universal 360° check including:Blood pressure, cholesterol, glucose, BMI, waist circumference, exercise plan, meal plan

Limited to R155 p/b1 per year p/b over the age of 18 years at DSP

Flu vaccinations Limited to R80 p/b

HPV (Cervical Cancer) One course (3 doses per registered schedule) per female beneficiaries between the ages of 12 and 18

Adult Pneumococcal Vaccine Subject to pre-authorisation, for beneficiaries over the age of 60 years

Tetanus vaccine One injection when required

Malaria prophylaxis As required

Mammogram One test per female beneficiary over the age of 35, every 24 months

Pap smear One test per female beneficiary over the age of 18 per annum

Prostate Specific Antigen (PSA) One test per male beneficiary over the age of 40 per annum

Quit smoking programmeLimited to R2 810, once in a lifetime.Cost of programme will be refunded after cotinine test proofs non-smoking

Glaucoma Screen Test One per beneficiary per year

Fitness Assessment and exercise prescription:

Access to Universal Network Biokineticists for:Annual fitness assessment

Exercise prescription Regular monitoring

Nutritional assessment and healthy eating plan:

Access to the Universal Network of dieticians for: Annual assessment

Healthy eating plan prescription Regular monitoring

Strict Protocols apply Strict Protocols apply

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Oral contraceptives Limited to R110 p/b per month

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Unlimited telephone counseling with referral for

one-on-one counseling to a maximum of

3 sessions per annum

Baby wellness visitTwo visits per annum for children between 4 weeks and

18 months at a DSP

Baby bag or voucher Value of R1 000

Childhood immunisationsApplicable to children up to the age of 12 years, as per

recommendation of the Department of Health

School readiness 5 - 7 years old

Psychometric testing 14 - 18 years

NEW!

Hospital benefits5The Pinnacle ED option offers comprehensive in-hospital benefits. As a member of the Pinnacle ED option you are covered at 100% of the AT (200% AT for specialists in-hospital) whilst in hospital. You must make use of a Netcare hospital, and all services in hospital have to be pre-authorised. Cover is unlimited for most services, but certain services have limits applicable. Limits may be related to a rand value, type of cover e.g. PMB or number of days.

Alternatives to hospitalisation are also covered on the Pinnacle ED option. Benefits are available for step-down nursing facilities, Hospice and rehabilitation. You are required to pre-authorise these treatments, and it is subject to protocols and case management.

Co-payments are payable on specified elective procedures (excluding PMBs) done in a hospital or a day facility. The following treatment requires a R1 000 co-payment: Excision lesion (benign & malignant).

The following treatments require a R1 500 co-payment: Gastroscopy, colonoscopy, cystoscopy, nasal/sinus endoscopy, functional nasal surgery (septoplasty), hysteroscopy, flexible sigmoidoscopy, arthroscopy, diagnostic laparoscopy, dental, joint replacements (arthroplasty), conservative back and neck treatment (spinal cord injections), laminectomy and spinal fusion, Nissen fundoplication (reflux surgery), hysterectomy (except for cancer).

The following treatments require a R2 000 co-payment: Laparoscopic Hemi-colectomy, Laparoscopic Inguinal hernia repair and Laparoscopic Appendicectomy.

In-hospital benefitsBenefit Unlimited Limited Description

Netcare hospitals. Nursing homesSubject to pre-authorisation. Co-payment for non-authorisation and voluntary use of non Netcare hospital

Ward fees: General, High care, Intensive care

100% AT, subject to pre-authorisation

Theatre fees 100% AT, subject to pre-authorisation

Medication whilst in hospital 100% AT

Take-out medicationSubject to MRP and formulary, limited to 7 (seven) days supply

GP costs whilst in hospital 100% AT

Specialist costs whilst in hospital 200% AT. Excluding dental

Surgical prostheses and electronic nuclear devices

100% AT, sub-limits apply

Basic radiology and pathology 100% AT

Specialised radiology including MRI/CT and PET scans

100% AT, pre-authorisation required. First R2 250 payable from MSA and AFB (accumulates to threshold)

Confinements

100% AT, pre-authorisation required, normal birth limited to 3 days and caesarean section limited to 4 days in-hospital, 12 antenatal visits and 2x 2D Scans. Payable at 100% of AT

Physiotherapy 100% AT

Mental health: psychiatric hospitalisation

Limited to 21 days p/f, subject to protocols and PMB’s, DSP only

Alcoholism, drug dependence and narcotism

PMB’s only

Organ transplants, plasmapheresis, renal dialysis

PMB’s only, subject to pre-authorisation and protocols, DSP onlyIncludes the transportation of the organ, surgically related procedures, professional fees and immunosuppressant drugs

Biological agentsSubject to pre-authorisation, protocols apply, limited to R224 720

Oncology Subject to pre-authorisation and protocols

Professional Sports injuries Subject to pre-authorisation, protocols apply

Alternatives to hospitalisationBenefit Unlimited Limited Description

Step-down nursing facilities, hospice and rehabilitation

100% ATSubject to pre-authorisation and protocols

Surgical procedures out-of-hospital100% ATSubject to pre-authorisation and protocols

Radial Keratotomy /Eximer Laser

Limited to R5 670 per eyeSubject to pre-authorisation, protocols and qualifying criteria, limit includes all related services and hospitalisation

6Hospital benefits

Surgical prostheses limits

Prescribed minimum benefits (PMBs)

Procedure (Non-PMB) LimitOverall Annual Limit for internal prosthesis (OAL) 50 000 Coronary Artery stents (subject to OAL)Plain (max of 3) 11 000 Medicated (max of 3) 17 000 Other Stents (subject to OAL)Aortic aneurysm stents Subject to OAL Carotid stents 15 000 Renal stents 5 000 Aneurysm coils 35 000 Heart valves (subject to OAL) 22 000 Orthopaedic Prostheses (subject to OAL) 2 Per family p/yHip prosthesis 37 500 Knee prosthesis 37 500 Shoulder prosthesis 37 500 Elbow prosthesis 37 500 Ankle prosthesis 25 000 Wrist prosthesis 25 000 Finger prosthesis 20 000 Spinal instrumentation - per level limited to 2 levels and one procedure per beneficiary per year

22 000

Spinal cages 11 000 Spinal implantable devices e.g balloons, cement used in kyphoplasty 25 000 Internal Fixators for fractures - pins, wires, intermedullary screws etc 25 000 Artificial limbs (subject to OAL)Through knee 50 000 Below knee 38 000 Above knee 44 000 Partial foot 19 000 Partial hand 12 000 Below elbow 35 000 Above elbow 40 000 Other prostheses (subject to OAL)Intra occular lenses 4 000 Bladder sling 6 000 Hernia Mesh 8 000 Vascular grafts 24 500 Electronic and Nuclear devices (subject to PMBs)Internal Cardiac defibrillator Subject to OAL Single chamber pacemaker Subject to OAL Dual chamber pacemaker Subject to OAL Internal nerve stimulators 100 000 Cochlear implants 175 000 Insulin pumps 22 000

Prescribed minimum benefits relating to hospitalisation, chronic conditions including HIV are covered at 100% of cost, subject to treatments protocols formularies and DSP’s.

Cover for chronic conditionsThe Pinnacle ED option covers 72 chronic conditions. The list of 72 chronic conditions are made up of 26 PMB CDL conditions and 46 additional non-PMB conditions. If you are diagnosed with one of the condition on the list, you need to register with Universal 086 011 1900 in order to qualify for the chronic benefit. The 26 PMB CDL conditions are payable from risk, and does not impact on your day-to-day benefits. The 46 non-PMB conditions are payable from the MSA and AFB, and are limited to R10 090 p/b and R15 150 p/f. An above threshold benefit of R3 785 p/f is available, only if the day-to-day limit has not been exceeded, subject to the overall above threshold benefit.

Chronic medication is subject to a formulary (list of medication) and Reference Pricing (RP).

The conditions covered on the Pinnacle option are:Addison’s Disease*, Allergic Rhinitis. Angina*, Ankylosing Spondylitis, Anorexia Nervosa, Asthma*, Attention Deficit Disorder, Barrett’s Oesophagus, Behcet’s Disease, Benign Prostatic Hyperplasia, Bipolar Mood Disorder*, Bronchiectasis*, Bulimia Nervosa, Cardiac Arrhythmias*, Cardiomyopathy*, Chronic Renal Failure*, Congestive Cardiac Failure*, Conn’s Syndrome, Chronic Obstructive Pulmonary Disease*, Emphysema*, Chronic Bronchitis, Connective Tissue Disorders (mixed), Coronary Artery Disease* , Crohn’s Disease*, Cushing’s Syndrome, Cystic Fibrosis, Deep Vein Thrombosis, Diabetes Insipidus*, Diabetes Mellitus Type 1*, Diabetes Mellitus Type 2*, Epilepsy*, Generalised Anxiety Disorder , Glaucoma*, Gastro-Oesophageal Reflux Disease, Gout, Haemophillia*, HIV/Aids*, Huntington’s Disease, Hypercholesterolaemia/Hyperlipidaemia*, Hypertension*, Hypoparathyroidism , Hypothyroidism*, Ischaemic Heart Disease*, Menopause/HRT*, Motor Neuron Disease, Multiple Sclerosis* Muscular Dystrophy, Myasthenia Gravis, Narcolepsy, Obsessive Compulsive Disorder, Osteoarthritis, Osteoporosis, Paget’s Disease of the Bone, Panic Disorder, Paraplegia/Quadriplegia, Parkinson’s Disease*, Pemphigus, Peripheral Arterio-sclerotic Disease, Polyarteritis Nodosa, Post-Traumatic Stress, Syndrome, Psoroasis/Psoriatic Arthritis, Pulmonary Interstitial Fibrosis, Rheumatoid Arthritis*, Schizophrenia*, Scleroderma (systemic sclerosis), Stroke, Systemic Lupus Erythematosus* Thrombocytopaenic Purpura, Ulcerative Colitis*, Unipolar Mood Disorder/Major Depression, Valvular Heart Disease, Zollinger-Ellison Syndrome

Contributions the Pinnacle Efficiency Discounted option

Pinnacle Principal Adult Child

Risk 2 904 2 258 816

Savings 876 684 240

Total 3 780 2 942 1 056

Annual savings 10 512 8 208 2 880

Annual Flexi Benefit (AFB) 2 388 1 860 660

Total day-to-day benefit 12 900 10 068 3 540

Annual threshold (incl AFB) 14 208 11 043 3 857

Annual self payment gap 1 308 975 317

A child dependant is a dependant who is under the age of 21 years. An adult dependant is a dependant who is 21 years or older. The above rates are only applicable to the member and a maximum of three of his/her child dependants.

GlossaryCompCare Medical Scheme

PMB Prescribed Minimum BenefitMSA Medical Savings AccountCDL Chronic Disease ListP/F Per familyRP Reference PricingTTO To Take Out i.e. medicines taken out of hospital when dischargedAFB Annual Flexi BenefitSPG Self Payment GapP/B Per beneficiaryAT Agreed TariffDSP Designated Service ProviderTL Threshold LimitOTC Over The Counter Medicine

This brochure is a summary of the benefits of CompCare Wellness Medical Scheme. All information relating to the 2015 CompCare Wellness Medical Scheme benefits and contributions are subject to formal approval by the Council for Medical Schemes. On joining the Scheme, all members will receive a detailed member brochure, as approved. The final registered Rules of the Scheme will apply.

Administered by Universal Healthcare Administrators (Pty) Ltd

Contact detailsContact details for complaints

escalated to the Council forMedical Schemes:

Tel: 086 112 3267E-mail: complaints@medicalschemes.com

Web: www.medicalschemes.com

Universal Place, 19 Tambach Road Sunninghill Park, Sandton | PO Box

1411, Rivonia, 2128

Tel: 086 122 2777 | Fax: 011 208 1028E-mail: admin@universal.co.za

Website: www.compcarewellness.co.za