The Pinnacle Option

Overview

The Pinnacle option offers comprehensive cover for the discerning achiever, with exceptional hospital and superior day-to-day benefits comprising a combination of savings account, traditional risk cover and very competitive above threshold benefits.

YOU CAN LOOK FORWARD TO EXCEPTIONAL VALUE AND BENEFITS FROM PINNACLE IN 2012

• You receive day-to-day benefits of up to R40 319 per family per annum
• We offer a benefit for oral contraceptives from risk
• You can select a medical service provider of your choice, without being locked into a restricted network
• Your specialist will be paid at 200% of the Agreed Tarriff (in-and-out of hospital)
• We offer unlimited oncology benefits for peace of mind
• We provide cover for professional sportsmen and women, for injuries relating to participation in professional sport
• We provide cover for 72 chronic conditions
• You now have a basket of wellness benefits - including preventative screening for blood pressure, glucose, cholesterol, BMI and waist circumference, certain baby immunisations, flu vaccinations, HPV (cervical cancer) vaccination, adult pneumococcal vaccination, pap smears, prostate specific antigen test, VCT test, baby wellness visits and malaria prophylaxis paid from risk, subject to protocols
• You pay only for the first three child dependants – the rest are free!

Day-to-Day Benefits

Annual Medical Savings and Annual Flexi Benefit for day-to-day expenses

P – Principal member A – Adult dependant C – Child dependant

Pinnacle	Annual Flexi Benefit
P	R10 561
P + A	R18 782
P + A + C	R21 721
P + A + 2C	R24 660
P + A + 3C	R27 599

Day-to-Day Benefits

Day-to-day claims are paid at 100% of the Agreed Tariff (AT), from the annual Medical Savings Account (MSA) - 20% of annual contributions. Once the savings have been depleted, claims are payable from the Annual Flexi Benefit (AFB) - 5% of annual contributions, where after the member is liable for the Self Payment Gap (SPG). During this period claims will accumulate to the threshold level at the Agreed Tariff, without the member being refunded. Once the threshold level is reached, the member will qualify for an above threshold benefit of R6 360 p/b, and R12 720 p/f, with specified sub-limits.

On All Income Categories	Medical Savings Account	Annual Flexi Benefit	Total Day-to-Day Benefit
Member	R8 448	R2 113	R10 561
Adult Dependant	R6 576	R1 645	R8 221
Child Dependant	R2 352	R587	R2 939

Day-to-day services payable from the MSA, AFB, SPG and Above Threshold Benefit (where applicable)*

Benefits	Limits	Above Threshold Benefit
GP consultations	Initially paid from MSA, AFB and SPG	Unlimited (not subject to the above threshold benefit)
Specialist consultations	200% AT.  Initially paid from MSA, AFB and SPG	*R3 180 p/f
Acute Medicine (25% co-payment on all medicine without a generic equivalent - member has the option to have this paid from available medical savings account without accumulation to the threshold).	Subject to formulary and MRP. Initially paid from MSA, AFB and SPG	*R2 650 p/f
Basic Radiology and Pathology	Initially paid from MSA, AFB and SPG	*R3 180 p/f (combined limit for radiology and pathology)
Basic dentistry	Initially paid from MSA, AFB and SPG	Unlimited (not subject to the above threshold benefit)
Auxiliary services	Paid from MSA and AFB and SPG Collective limit of R5 300 p/f	*R2 120 p/f for physiotherapy and bio kinetics

*Accumulates to the threshold level, unless otherwise specified

Day-to-day services paid from MSA and AFB*

Benefits	Limits
Over-the-counter medicine (including schedule 0,1 and 2 medicines) and Homeopathic medicines	Paid from MSA and AFB, subject to formulary and MRP, limited to R750 p/b and R1 060 p/f (limited to one script per day and a maximum of R160 per event) - does not accumulate to the above threshold level
Specialised Dentistry	Paid from MSA and AFB, limited to R10 600 p/b.  Subject to protocols.
Optometry Visits Lenses Frames and contact lenses	Paid from MSA and AFB 2 p/b Limited to R3 180 p/b per annum, subject to protocols Frame sub-limit included in lens limit R1 600 p/b per annum
Clinical psychology	Paid from MSA and AFB, limited to R 3 500 p/f Subject to protocols.
Psychiatry	Paid from MSA and AFB, limited to R11 660 p/f Subject to protocols.
Home Oxygen Ventilation	Paid from MSA and AFB, subject to pre-authorisation, PMBs and protocols
Private nursing at home	100% GWR, paid from MSA and AFB, limited to 60 days, subject to protocols and pre-authorisation
Ante-natal classes	Paid from MSA and AFB, limited to R950. Subject to protocols.
Hospital emergency room/casualty emergency visits (not requiring admissions excluding facility fees)	Paid from MSA and AFB

*Accumulates to the threshold level, unless otherwise specified

Day-to-day services not subject to MSA or AFB paid from Risk

Benefits	Limits
Surgical & medical appliances	100% of cost, R47 700 p/f, sub-limits apply - click here for details
Emergency road-side assistance and ambulance transportation	Unlimited.  Preferred Provider.

Wellness, lifestyle and preventative care benefits paid from risk

Benefits	Limits
Women's Health
Cervical Cancer Vaccine	1 course (3 doses per registered schedule), once-off for female beneficiaries between the ages of 12 and 18 years
Pap smear	1 test per year per female beneficiary over the age of 18 years
Oral contraceptives	Limited to R100 p/b per month
Men’s health
Prostate specific antigen	1 test annually per male beneficiary over the age of 40 years
Children’s health
Baby wellness visits	2 visits per annum for children between 4 weeks and 18 months at DSP
Vaccinations
Flu vaccine	1 p/b per year, limited to R70
Tetanus diphtheria injection	As required
Pneumococcal vaccine	As required, p/b over 60 years of age and high risk members, subject to pre-authorisation
Prophylaxis (malaria)	As required
Lifestyle
Universal 360° check including cholesterol, glucose, blood pressure, BMI, waist circumference, exercise plan, meal plan	1 per year p/b over the age of 18 years, limited to R100 p/b at DSP
Smoking cessation programme	Once a lifetime p/b.  Limited to R2 500 Conditions apply.
VCT and HIV	Once a year p/b

 

Cover for Chronic Conditions

The Pinnacle option offers extensive cover for 72 chronic conditions, including the 26 Chronic Disease List (CDL) conditions and additional 46 non-CDL conditions. If you suffer from one of the chronic conditions on the list, you need to register with Mediscor in order to qualify for the chronic benefit. Chronic medication is subject to the standard formulary and Mediscor Reference Pricing (MRP). A 25% co-payment is payable for the voluntary use of non-formulary or non-generic medicines.

Registered CDL chronic medication is unlimited. Non-CDL chronic medication is paid from the MSA, AFB and Self Payment Gap, limited to R8 480 p/b and R12 720 p/f. An above threshold benefit of R3 180 p/f is available (only if the limit mentioned above has not been exceeded), subject to the overall above threshold limit.

Insulin dependent members may join the diabetes programme with our preferred provider Centre for Diabetes and Endocrinology (CDE).

In-hospital Benefits

Benefits	Limits
Overall Annual Limit (subject to pre-authorisation)	Unlimited.  Co-payments are payable for certain elective procedures. Co-payments may be paid from the MSA with no accumulation to the threshold
TTO Medication (take home medication)	Limited to 7 days supply
GP and specialist cost: • GPs • Specialists	Unlimited 100% of AT 200% of AT
Surgical prosthesis & electronic nuclear devices	Limits per category, sub-limits apply, subject to pre-authorisation and protocols, click here for details
Radiology and Pathology	100% of AT, unlimited
MRI, CT scans and PET scans (combined in and out of hospital benefit)	100% of AT, unlimited. First R2 000 paid from MSA (with accumulation to the threshold), pre-authorisation required
Physiotherapy in hospital	100% of AT, unlimited
Organ transplants, renal dialysis (includes transportation of the organ, surgically related procedures, professional fees and services, as well as immunosuppressant drugs)	100% of AT, PMBs only, subject to pre-authorisation, protocols, and DSP
Sport injuries	100% of AT, including professional sport
Emergency room/casualty	100% of AT for emergency medical treatment for injuries resulting from accidents or trauma

Alternatives to Hospitalisation

The Pinnacle option offers cover for step-down nursing facilities, Hospice and rehabilitation. Cover is subject to pre-authorisation, protocols and case management.

Prescribed Minimum Benefits (PMB's)

• Subject to Scheme protocols
• Hospitalisation – 100% of cost at DSP, unlimited
• AT at DSP
• Medication – CDL conditions are unlimited subject to a formulary and dispensed by a DSP
• Medical management in and out of hospital – 100% of AT, subject to protocols and treatment by DSP
• HIV/AIDS – subject to registration on HIV/AIDS programme, subject to protocols, failing which a R3 000 limit will apply

Co-Payments

Co-payments are payable on specified elective procedures (excluding PMBs) done in a hospital or a day facility. The following treatments require a R1500 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 treatment requires a R1000 co-payment:
Excision lesion (benign & malignant)

Contributions Table

	Principal	Adult	Child
Risk	R2 818	R2 194	R782
Medical Savings Account	R704	R548	R196
Total Contribution	R3 522	R2 742	R978
Annual day-to-day benefits before threshold (MSA and AFB)	R10 561	R8 221	R2 939
Annual Self Payment Gap	R1 218	R963	R311
Threshold	R11 779	R9 184	R3 250

Glossary

• PMB - Prescribed Minimum Benefit
• AFB - Annual Flexi Benefit
• MSA - Medical Savings Account
• SPG - Self Payment Gap
• CDL - Chronic Disease List
• P/B - Per Beneficiary
• P/F - Per Family
• AT - Agreed Tariff
• MRP - Mediscor Reference Pricing
• CDE - Centre for Diabetes and Endichronology   
• TTO - To Take Out i.e. medicines taken out of hospital when discharged
• DSP - Designated Service Provider
• GWR - General Ward Rate