docCompcare All Plan Comparison 2015
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Compcare All Plan Comparison 2015
Benefits Axis - 2015 Axis ED - 2015 Plan Type Hospital Plan Plan Operation - Hospitalisation 100% of Agreed Tariff Hospital Plan 100% of Agreed Tariff - Day-to-day Limited post operative rehabilitation benefit Limited post operative rehabilitation benefit Overall Annual Maximum Hospital Benefit Unlimited Unlimited 1 Private Hospital Care Any Private Hospital 2 Co-payment 3 Oncology Certain procedures, Endoscopies and Scans (R1000 to R8000) OAL and Protocols apply. R112 360 for Biological agents (25% co-pay) Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to 3 days and 2 nights Limited to 4 days and 3 nights Limited to 7 days supply per event DSP. 21 days p/f. Rehabilitation for PMB's only 4 Organ Transplants 5 Dialysis 6 Maternity - Natural Birth - Elective Ceasarean 7 To take home medication 8 Psychiatric Hospitalisation Radiology/Pathology/Prosthesis 1 Basic Radiology Unlimited, subject to protocols 2 MRI, CT & PET Scans Limited to R15 170 per family 3 Pathology Limited to R25 170 p/f, unless otherwise authorised 4 Internal Prosthesis PMB's only. Protocols apply 5 External No benefit Appliances/Prosthesis Sub Acute Facilities 1 Hospice Unlimited, case management/protocols/pre-auth. 2 Nursing No benefit 3 Ambulance Services Unlimited Chronic Benefit 27 CDL chronic conditions Unlimited - DSP (Mediscor) and Formulary applies Netcare hospitals only/ 30% co-pay with R5000 minimum at others (except emergencies) Certain procedures, Endoscopies and Scans (R1000 to R8000) OAL and Protocols apply. R112 360 for Biological agents (25% co-pay) Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to 3 days and 2 nights Limited to 4 days and 3 nights Limited to 7 days supply per event DSP. 21 days p/f. Rehabilitation for PMB's only Dynamix - 2015 Hybrid - Savings and Traditional combined 100% of Agreed Tariff MSA, AFB ( Annual Flexi Benefit - AFB), Self Payment Gap, and ATB Unlimited Any Private Hospital Certain procedures, Endoscopies and Scans (R1000 - R2000) Unlimited. Protocols apply. R168 540 for Biological agents (25% co-pay) Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to 3 days and 2 nights Limited to 4 days and 3 nights Limited to 7 days supply per event DSP. 21 days p/f. Rehabilitation for PMB's only Unlimited, subject to protocols Limited to R15 170 per family Limited to R25 170 p/f, unless otherwise authorised PMB's only. Protocols apply Unlimited, subject to protocols Unlimited, first R2 250 paid from savings (with accumulation) Unlimited, subject to protocols Protocols and various limits apply No benefit R17 640 p/f, subject to sublimits, paid from Risk Unlimited, case management/protocols/pre-auth. No benefit Unlimited Unlimited, case management/protocols/pre-auth. MSA & AFB apply, in lieu of hospitalisation Unlimited Unlimited - DSP (Mediscor) and Formulary applies Unlimited - DSP (Mediscor) and Formulary applies 36 conditions: M R7 570, M1+ R12 625. Paid from MSA and AFB, ATB of R2520 Additional chronic conditions No benefit No benefit Day-to-day Benefit Overall Annual Maximum Only post operative rehab, limited to R2750/14 days Only post operative rehab, limited to R2750/14 days Preferred Provider N/a N/a Medical Savings Account N/a N/a Annual Threshold Self Payment Gap Above Threshold Benefit GP's and medication 1 General Practitioners 2 Specialists 3 Prescribed Medication 4 Pharmacy Advised Medicine Radiology & Pathology 1 Basic Radiology 2 MRI, CT & PET Scans 3 Pathology Dental Benefit 1 Conservative Dentistry 2 Specialised Dentistry Optical Benefit 1 Examination 2 Lenses 3 Frames 4 Contact Lenses Auxilliary Services 1 Physiotherapy 2 Psychiatry 3 Psychology HIV / AIDS Financial and Demographic 1 Date of information 2 Principal Members 3 Administrator 4 Scheme (Option) age profile 5 Solvency ratio 6 Past Scheme increases Contributions N/a N/a N/a N/a N/a N/a 15% MSA, 5% AFB(Annual Flexi Benefit) and limited ATB Any GP, Specialist. 10% credit to AFB for use of Network Providers 15%(Member)+5%(Scheme) - PM: R7704, AD: R6024, C: R2232 PM: R10 620, AD: R8286, C: R3050 PM: R2916, AD: R2262, C: R818 R5055 p/b and R10 110 p/f, & specified sublimits No benefit No benefit No benefit No benefit No benefit No benefit No benefit No benefit Subject to MSA, AFB and ATB - unlimited in ATB 100% - Subject to MSA, AFB & ATB. ATB limit: R3275 p/f Subject to MSA, AFB & ATB. ATB limit: R2520 p/f R170 per script, limited to: Single R730, Family R1070 No benefit Combined with In-hospital limit No benefit No benefit Combined with In-hospital limit No benefit Subject to MSA, AFB and ATB - ATB limit : R2520 p/f Combined with In-hospital limit Combined with Radiology benefit No benefit No benefit No benefit No benefit Subject to MSA, AFB and ATB - Unlimited Subject to MSA & AFB, Limits: M R9 530, M1+ R13 260 No benefit No benefit No benefit No benefit No benefit No benefit No benefit No benefit Subject to MSA, 2 consultations p/b per annum Subject to MSA and AFB and R3 030 p/b/p/a Combined with Lenses benefit, R1270 sublimit Included in Lenses benefit limit No benefit No benefit No benefit Unlimited, registration recommended No benefit No benefit No benefit Unlimited, registration recommended Subject to MSA, AFB & ATB - R1640 limit per family Subject to MSA & AFB - R8 200 limit p/f Subject to MSA & AFB - R1910 limit p/f Unlimited, registration recommended December 31, 2013 Scheme - 12 610 Axis Options - 783 Universal Healthcare Administrators (Pty) Ltd Average age- 37.1(43.0); Pensioner %- 12.7%(17.8%) 42.10% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% December 31, 2013 Scheme - 12 610 Axis Options - 783 Universal Healthcare Administrators (Pty) Ltd Average age- 37.1(43.0); Pensioner %- 12.7%(17.8%) 42.10% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% December 31, 2013 Scheme - 12 610 Dynamix Options - 1 586 Universal Healthcare Administrators (Pty) Ltd Average age- 37.1(44.6); Pensioner %- 12.7%(21.7%) 42.10% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% Salary Brackets All All All Principal Member 1436 1077 3323 Principal Member + Spouse 2872 2154 5920 Principal + Spouse + 1 Child 3316 2493 6849 Principal + Spouse + 2 Children 3760 2832 7778 Principal + Spouse + 3 Children 4204 3171 8707 E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail. Benefits Dynamix ED - 2015 Mumed - 2015 Mumed ED - 2015 Plan Type Hybrid - Savings and Traditional combined Traditional limited Traditional limited Plan Operation - Hospitalisation 100% of Agreed Tariff 100% of Agreed Tariff 100% of Agreed Tariff - Day-to-day MSA, AFB ( Annual Flexi Benefit - AFB) and ATB Limited to AFB ( Annual Flexi Benefit - AFB) Limited to AFB ( Annual Flexi Benefit - AFB) Overall Annual Maximum Unlimited R1.5 million per family R1.5 million per family Hospital Benefit Netcare hospitals only/ 30% co-pay with R5000 minimum Netcare hospitals only/ 30% co-pay with R5000 minimum at 1 Private Hospital Care Any Private Hospital at others (except emergencies) others (except emergencies) Certain procedures, Endoscopies and Scans (R1000 2 Co-payment Certain procedures, Endoscopies and Scans (R1000 to R8000) Certain procedures, Endoscopies and Scans (R1000 to R8000) R2000) Unlimited. Protocols apply. R168 540 for Biological OAL and Protocols apply. R112 360 for Biological agents OAL and Protocols apply. R112 360 for Biological agents 3 Oncology agents (25% co-pay) (25% co-pay) (25% co-pay) 4 Organ Transplants Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to PMB conditions at DSP 5 Dialysis Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to PMB conditions at DSP 6 Maternity - Natural Birth Limited to 3 days and 2 nights Limited to 3 days and 2 nights Limited to 3 days and 2 nights - Elective Ceasarean Limited to 4 days and 3 nights Limited to 4 days and 3 nights Limited to 4 days and 3 nights 7 To take home medication Limited to 7 days supply per event Limited to 7 days supply per event Limited to 7 days supply per event 8 Psychiatric Hospitalisation DSP. 21 days p/f. Rehabilitation for PMB's only DSP. 21 days p/f. Rehabilitation for PMB's only DSP. 21 days p/f. Rehabilitation for PMB's only Radiology/Pathology/Prosthesis 1 Basic Radiology Unlimited, subject to protocols R25 840 per family, subject to OAL R25 840 per family, subject to OAL Unlimited, first R2 250 paid from savings (with 2 MRI, CT & PET Scans Limited to R13 100 per family Limited to R13 100 per family accumulation) 3 Pathology Unlimited, subject to protocols R19 550 per family, subject to OAL R19 550 per family, subject to OAL 4 Internal Prosthesis Protocols and various limits apply Protocols and various limits apply Protocols and various limits apply 5 External R17 640 p/f, subject to sublimits, paid from Risk R6 850 p/f, subject to sublimits, paid from Risk R6 850 p/f, subject to sublimits, paid from Risk Appliances/Prosthesis Sub Acute Facilities 1 Hospice Unlimited, case management/protocols/pre-auth. Unlimited, case management/protocols/pre-auth. Unlimited, case management/protocols/pre-auth. 2 Nursing MSA & AFB apply, in lieu of hospitalisation MSA & AFB apply, in lieu of hospitalisation MSA & AFB apply, in lieu of hospitalisation 3 Ambulance Services Unlimited Unlimited Unlimited Chronic Benefit 27 CDL chronic conditions Unlimited - DSP (Mediscor) and Formulary applies Unlimited - DSP (Mediscor) and Formulary applies Unlimited - DSP (Mediscor) and Formulary applies 36 conditions: M R7 570, M1+ R12 625. Paid from MSA Additional chronic conditions No benefit No benefit and AFB, ATB of R2520 Day-to-day Benefit Overall Annual Maximum 18% MSA, 5% AFB(Annual Flexi Benefit) and limited ATB AFB - PM: R4944, AD: R3096, C: R1236 AFB - PM: R4944, AD: R3096, C: R1236 Any GP, Specialist. 10% credit to AFB for use of Network Any GP, Specialist. 10% credit to AFB for use of Network Any GP, Specialist. 10% credit to AFB for use of Network Preferred Provider Providers Providers Providers 15%(Member)+5%(Scheme) - PM: R7704, AD: R6024, Medical Savings Account N/a N/a C: R2232 Annual Threshold PM: R10 620, AD: R8286, C: R3050 N/a N/a Self Payment Gap PM: R2916, AD: R2262, C: R818 N/a N/a Above Threshold Benefit R5055 p/b and R10 110 p/f, & specified sublimits N/a N/a GP's and medication 1 General Practitioners Subject to MSA, AFB and ATB - unlimited in ATB OAL: M 6 visits, M1 8 visits, M2 10 visits, M3+ 11 visits OAL: M 6 visits, M1 8 visits, M2 10 visits, M3+ 11 visits 2 Specialists 100% - Subject to MSA, AFB & ATB. ATB limit: R3275 p/f Subject to AFB limit Subject to AFB limit 3 Prescribed Medication Subject to MSA, AFB & ATB. ATB limit: R2520 p/f Subject to AFB limit and Formulary Subject to AFB limit and Formulary 4 Pharmacy Advised Medicine R170 per script, limited to: Single R730, Family R1070 R145 per script, limited to: Single R490, Family R865 R145 per script, limited to: Single R490, Family R865 Radiology & Pathology 1 Basic Radiology Subject to MSA, AFB and ATB - ATB limit : R2520 p/f Subject to AFB limit Subject to AFB limit 2 MRI, CT & PET Scans Combined with In-hospital limit Combined with In-hospital limit Combined with In-hospital limit 3 Pathology Combined with Radiology benefit Subject to AFB limit Subject to AFB limit Dental Benefit 1 Conservative Dentistry Subject to MSA, AFB and ATB - Unlimited Subject to AFB limit, thereafter unlimited Subject to AFB limit, thereafter unlimited 2 Specialised Dentistry Subject to MSA & AFB, Limits: M R9 530, M1+ R13 260 Subject to AFB limit: Limited to R1700 p/b Subject to AFB limit: Limited to R1700 p/b Optical Benefit 1 Examination Subject to MSA, 2 consultations p/b per annum MSA & AFB, 1 consultation p/b per annum MSA & AFB, 1 consultation p/b per annum 2 Lenses Subject to MSA and AFB and R3 030 p/b/p/a Subject to AFB limit, sublimit of R1315 p/b and R3795 p/f Subject to AFB limit, sublimit of R1315 p/b and R3795 p/f 3 Frames Combined with Lenses benefit, R1270 sublimit Combined with Lenses benefit, R660 sublimit Combined with Lenses benefit, R660 sublimit 4 Contact Lenses Included in Lenses benefit limit Included in Lenses benefit limit Included in Lenses benefit limit Auxilliary Services 1 Physiotherapy Subject to MSA, AFB & ATB - R1640 limit per family Subject to AFB limit : R1645 p/b and R2615 p/f Subject to AFB limit : R1645 p/b and R2615 p/f 2 Psychiatry Subject to MSA & AFB - R8 200 limit p/f Subject to AFB limit : R3 455 p/f Subject to AFB limit : R3 455 p/f 3 Psychology Subject to MSA & AFB - R1910 limit p/f Subject to AFB limit : R1 375 p/b and R3 455 p/f sublimit Subject to AFB limit : R1 375 p/b and R3 455 p/f sublimit HIV / AIDS Unlimited, registration recommended Unlimited, registration recommended Unlimited, registration recommended Financial and Demographic 1 Date of information December 31, 2013 December 31, 2013 December 31, 2013 2 Principal Members Scheme - 12 610 Dynamix Options - 1 586 Scheme - 12 610 Mumed Options - 3 049 Scheme - 12 610 Mumed Options - 3 049 3 Administrator Universal Healthcare Administrators (Pty) Ltd Universal Healthcare Administrators (Pty) Ltd Universal Healthcare Administrators (Pty) Ltd 4 Scheme (Option) age profile Average age- 37.1(44.6); Pensioner %- 12.7%(21.7%) Average age- 37.1(32.7); Pensioner %- 12.7%(7.4%) Average age- 37.1(32.7); Pensioner %- 12.7%(7.4%) 5 Solvency ratio 42.10% 42.10% 42.10% 6 Past Scheme increases 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% Contributions All R0 R6000 R6001 R7900 R7901 R15000 Principal Member 2815 Principal Member + Spouse 5012 1563 1731 1886 2097 2774 3082 3357 3731 Principal + Spouse + 1 Child 5800 3217 3575 3892 Principal + Spouse + 2 Children 6588 3660 4068 Principal + Spouse + 3 Children 7376 4103 4561 Salary Brackets R15001+ R0 R6000 R6001 R7900 R7901 R15000 1296 1429 1548 1717 2296 2534 2759 3054 4322 2662 2942 3195 3533 4427 4913 3028 3350 3631 4012 4962 5504 3394 3758 4067 4491 E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail. R15001+ Benefits Mumed ED Network - 2015 Plan Type Capitation (Designated Service Providers) Plan Operation - Hospitalisation 100% of Agreed Tariff - Day-to-day Limited to AFB ( Annual Flexi Benefit - AFB) Overall Annual Maximum R1.5 million per family Hospital Benefit Netcare hospitals only/ 30% co-pay with R5000 1 Private Hospital Care minimum at others (except emergencies) Certain procedures, Endoscopies and Scans (R1000 2 Co-payment to R8000) OAL and Protocols apply. R112 360 for Biological 3 Oncology agents (25% co-pay) 4 Organ Transplants Limited to PMB conditions at DSP 5 Dialysis Limited to PMB conditions at DSP 6 Maternity - Natural Birth Limited to 3 days and 2 nights - Elective Ceasarean Limited to 4 days and 3 nights 7 To take home medication Limited to 7 days supply per event 8 Psychiatric Hospitalisation DSP. 21 days p/f. Rehabilitation for PMB's only Radiology/Pathology/Prosthesis 1 Basic Radiology R25 840 per family, subject to OAL 2 MRI, CT & PET Scans Limited to R13 100 per family 3 Pathology R19 550 per family, subject to OAL 4 Internal Prosthesis Protocols and various limits apply 5 External R6 850 p/f, subject to sublimits, paid from Risk Appliances/Prosthesis Sub Acute Facilities 1 Hospice Unlimited, case management/protocols/pre-auth. 2 Nursing MSA & AFB apply, in lieu of hospitalisation 3 Ambulance Services Unlimited Chronic Benefit 27 CDL chronic conditions Unlimited - DSP (Mediscor) and Formulary applies Additional chronic conditions No benefit Day-to-day Benefit Overall Annual Maximum AFB - PM: R4944, AD: R3096, C: R1236 Any GP, Specialist. 10% credit to AFB for use of Preferred Provider Network Providers Medical Savings Account N/a Annual Threshold N/a Self Payment Gap N/a Above Threshold Benefit N/a GP's and medication NetworX - 2015 NetworX ED - 2015 Capitation (Designated Service Providers) 100% of Agreed Tariff Designated Service Providers & set limits R1 000 000 per family Capitation (Designated Service Providers) 100% of Agreed Tariff Designated Service Providers & set limits R1 000 000 per family Any Private Hospital Public Hospitals only. No benefit for Private facilities None None PMB's only, subject to OAL and protocols PMB's only, subject to protocols Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to 3 days and 2 nights Limited to 4 days and 3 nights Limited to R250 per discharge at DSP Hospital 21 days p/f at DSP. Rehabilitation for PMB's only Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to 3 days and 2 nights Limited to 4 days and 3 nights Limited to R250 per discharge at DSP Hospital 21 days p/f at DSP. Rehabilitation for PMB's only Unlimited, subject to case management, protocols AOL applies, subject to protocols Unlimited, subject to case management, protocols, DSP PMB's only. Protocols apply Unlimited, subject to case management, protocols AOL applies, subject to protocols Unlimited, subject to case management, protocols, DSP PMB's only. Protocols apply PMB's only PMB's only Limited to OAL, case management/protocols/pre-auth. No benefit Unlimited Limited to OAL, case management/protocols/pre-auth. No benefit Unlimited Unlimited - DSP (Mediscor) and Formulary applies No benefit Unlimited - DSP (Mediscor) and Formulary applies No benefit Annual Flexi Benefit: Single R2532, Family R3780 Member must select from a list of contracted GP provider network N/a N/a N/a N/a Annual Flexi Benefit: Single R2532, Family R3780 Member must select from a list of contracted GP provider network N/a N/a N/a N/a Unlimited : Subject to DSP GP. 2 non DSP visits p/b - R900 per event, 20% co-payment Subject to AFB limit, 2 visits p/b & 3 p/f, on referral Unlimited if prescribed by DSP GP, Formulary applies No benefit 1 General Practitioners OAL: M 6 visits, M1 8 visits, M2 10 visits, M3+ 11 visits 2 Specialists 3 Prescribed Medication 4 Pharmacy Advised Medicine Radiology & Pathology 1 Basic Radiology 2 MRI, CT & PET Scans 3 Pathology Dental Benefit 1 Conservative Dentistry 2 Specialised Dentistry Optical Benefit 1 Examination Subject to AFB limit Subject to AFB limit and Formulary R145 per script, limited to: Single R490, Family R865 Unlimited : Subject to DSP GP. 2 non DSP visits p/b - R900 per event, 20% co-payment Subject to AFB limit, 2 visits p/b & 3 p/f, on referral Unlimited if prescribed by DSP GP, Formulary applies No benefit Subject to AFB limit Combined with In-hospital limit Subject to AFB limit Specific list of black & white x-rays, subject to referral No benefit, except PMB's PMB's only at DSP (GP referral) Specific list of black & white x-rays, subject to referral No benefit, except PMB's PMB's only at DSP (GP referral) Subject to AFB limit, thereafter unlimited Subject to AFB limit: Limited to R1700 p/b Subject to AFB: PMB's only Subject to AFB limit: PMB's only Subject to AFB: PMB's only Subject to AFB limit: PMB's only MSA & AFB, 1 consultation p/b per annum Subject to AFB limit, sublimit of R1315 p/b and R3795 p/f Combined with Lenses benefit, R660 sublimit Included in Lenses benefit limit Subject to AFB limit: One consultation p/b per 24 months Subject to AFB limit: One consultation p/b per 24 months Single vision R695 p/b, or bifocal R1113 p/b x 24 mths Single vision R695 p/b, or bifocal R1113 p/b x 24 mths Limited range within DSP network No benefit Limited range within DSP network No benefit Subject to AFB limit : R1645 p/b and R2615 p/f Subject to AFB limit : R3 455 p/f Subject to AFB limit : R1 375 p/b and R3 455 p/f sublimit Unlimited, registration recommended No benefit No benefit No benefit No benefit No benefit No benefit Unlimited, registration recommended Unlimited, registration recommended December 31, 2013 Scheme - 12 610 Mumed Options - 3 049 Universal Healthcare Administrators (Pty) Ltd Average age- 37.1(32.7); Pensioner %- 12.7%(7.4%) 42.10% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% December 31, 2013 Scheme - 12 610 NetworX Options - 3 337 Universal Healthcare Administrators (Pty) Ltd Average age- 37.1(24.5); Pensioner %- 12.7%(0.5%) 42.10% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% December 31, 2013 Scheme - 12 610 NetworX Options - 3 337 Universal Healthcare Administrators (Pty) Ltd Average age- 37.1(24.5); Pensioner %- 12.7%(0.5%) 42.10% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% 2 Lenses 3 Frames 4 Contact Lenses Auxilliary Services 1 Physiotherapy 2 Psychiatry 3 Psychology HIV / AIDS Financial and Demographic 1 Date of information 2 Principal Members 3 Administrator 4 Scheme (Option) age profile 5 Solvency ratio 6 Past Scheme increases Contributions Salary Brackets R0 R7900 R7901 R15000 R15001+ R0 R500 R501 R4000 Principal Member 1212 1321 1469 325 540 Principal Member + Spouse 2158 2351 2612 650 1020 1053 Principal + Spouse + 1 Child 2504 2727 3027 808 1203 1242 Principal + Spouse + 2 Children 2850 3103 3442 966 1386 1431 Principal + Spouse + 3 Children 3196 3479 3857 1124 523 1569 R4001 R5000 1620 R5001 R6000 R6001 R8000 R0 R500 646 676 310 1259 1319 616 699 881 1486 1556 784 873 1096 1713 1793 952 1047 2030 1120 1940 R501 R4000 353 1221 E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail. R4001 R6000 452 1311 1526 R6001 R9000 539 1051 1307 1563 1819 R9001 R10000 571 1114 1386 1658 1930 Benefits Pinnacle - 2015 Plan Type New Generation with Threshold Plan Operation - Hospitalisation 100% of Agreed Tariff, 200% Specialist cover MSA, AFB ( Annual Flexi Benefit - AFB), Self Payment Gap, - Day-to-day and ATB Overall Annual Maximum Unlimited Hospital Benefit Pinnacle ED - 2015 New Generation with Threshold 100% of Agreed Tariff, 200% Specialist cover MSA, AFB ( Annual Flexi Benefit - AFB), Self Payment Gap, and ATB Unlimited Netcare hospitals only/ 30% co-pay with R5000 minimum at others (except emergencies) 1 Private Hospital Care Any Private Hospital 2 Co-payment Certain procedures, Endoscopies and Scans (R1000 - R2000) Certain procedures, Endoscopies and Scans (R1000 - R2000) 3 Oncology Unlimited. Protocols apply. R224 720 for Biological agents 4 Organ Transplants Limited to PMB conditions at DSP 5 Dialysis Limited to PMB conditions at DSP 6 Maternity - Natural Birth Limited to 3 days and 2 nights - Elective Ceasarean Limited to 4 days and 3 nights 7 To take home medication Limited to 7 days supply per event 8 Psychiatric Hospitalisation DSP. 21 days p/f. Rehabilitation for PMB's only Radiology/Pathology/Prosthesis 1 Basic Radiology Unlimited, subject to protocols 2 MRI, CT & PET Scans Unlimited, first R2 250 paid from savings (with accumulation) 3 Pathology Unlimited, subject to protocols 4 Internal Prosthesis Protocols and various limits apply 5 External R56 180 p/f, subject to sublimits, paid from Risk Appliances/Prosthesis Sub Acute Facilities 1 Hospice Unlimited, case management/protocols/pre-auth. 2 Nursing MSA & AFB apply, in lieu of hospitalisation 3 Ambulance Services Unlimited Chronic Benefit 27 CDL chronic conditions Unlimited - DSP (Mediscor) and Formulary applies 45 conditions: M R10 090, M1+ R15 150. Paid from MSA and Additional chronic conditions AFB, ATB of R3785 Day-to-day Benefit Overall Annual Maximum 20% MSA, 5% AFB(Annual Flexi Benefit) and limited ATB Any GP, Specialist. 10% credit to AFB for use of Network Preferred Provider Providers 20%(Member)+5%(Scheme) - PM: R12 900, AD: R10 068, C: Medical Savings Account R3540 Annual Threshold PM: R14 208, AD: R11 043, C: R3 857 Self Payment Gap PM: R1303, AD: R975, C: R317 Above Threshold Benefit R7525 p/b and R15 135 p/f, & specified sublimits GP's and medication 1 General Practitioners Subject to MSA, AFB and ATB - unlimited in ATB 2 Specialists 200% - Subject to MSA, AFB & ATB. ATB limit: R3785 p/f 3 Prescribed Medication Subject to MSA, AFB & ATB. ATB limit: R3150 p/f 4 Pharmacy Advised Medicine R180 per script, limited to: Single R840, Family R1190 Radiology & Pathology 1 Basic Radiology R3785 p/f, Subject to MSA, AFB and ATB 2 MRI, CT & PET Scans Combined with In-hospital limit 3 Pathology Combined with Radiology benefit Dental Benefit 1 Conservative Dentistry Subject to MSA, AFB and ATB - Unlimited 2 Specialised Dentistry Subject to MSA and AFB - R14 575 p/b sublimit Optical Benefit 1 Examination MSA & AFB, 2 consultations p/b per annum 2 Lenses Subject to MSA and ATB - R3 785 p/b 3 Frames Combined with Lenses benefit, R1910 sublimit 4 Contact Lenses Included in Lenses benefit limit Auxilliary Services 1 Physiotherapy Subject to MSA, AFB and ATB - R2530 limit p/f 2 Psychiatry Subject to MSA and ATB - R13 885 limit p/f 3 Psychology Subject to MSA and ATB - R4155 limit p/f HIV / AIDS Unlimited, registration recommended Financial and Demographic 1 Date of information December 31, 2013 2 Principal Members Scheme - 12 610 Pinnacle Options - 1 134 3 Administrator Universal Healthcare Administrators (Pty) Ltd 4 Scheme (Option) age profile Average age- 37.1(47.5); Pensioner %- 12.7%(22.8%) 5 Solvency ratio 42.10% 6 Past Scheme increases 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% Contributions Symmetry - 2015 Traditional limited 100% of Agreed Tariff Limited to AFB ( Annual Flexi Benefit - AFB) Unlimited Any Private Hospital Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to 3 days and 2 nights Limited to 4 days and 3 nights Limited to 7 days supply per event DSP. 21 days p/f. Rehabilitation for PMB's only Certain procedures, Endoscopies and Scans (R1000 to R4000) Unlimited. Protocols apply. R112 360 for Biological agents (25% co-pay) Limited to PMB conditions at DSP Limited to PMB conditions at DSP Limited to 3 days and 2 nights Limited to 4 days and 3 nights Limited to 7 days supply per event DSP. 21 days p/f. Rehabilitation for PMB's only Unlimited, subject to protocols Unlimited, first R2 250 paid from savings (with accumulation) Unlimited, subject to protocols Protocols and various limits apply Unlimited, subject to protocols Limited to R15 170 per family Limited to R25 165 p/f, unless otherwise authorised Protocols and various limits apply R56 180 p/f, subject to sublimits, paid from Risk R13 260 p/f, subject to sublimits, paid from Risk Unlimited, case management/protocols/pre-auth. MSA & AFB apply, in lieu of hospitalisation Unlimited Unlimited, case management/protocols/pre-auth. MSA & AFB apply, in lieu of hospitalisation Unlimited Unlimited. Protocols apply. R224 720 for Biological agents Unlimited - DSP (Mediscor) and Formulary applies Unlimited - DSP (Mediscor) and Formulary applies 45 conditions: M R10 090, M1+ R15 150. Paid from MSA and 19 Conditions - M R3 785, M1+ R5 670. CDL initially paid AFB, ATB of R3785 from here 20% MSA, 5% AFB(Annual Flexi Benefit) and limited ATB Any GP, Specialist. 10% credit to AFB for use of Network Providers 20%(Member)+5%(Scheme) - PM: R12 900, AD: R10 068, C: R3540 PM: R14 208, AD: R11 043, C: R3 857 PM: R1303, AD: R975, C: R317 R7525 p/b and R15 135 p/f, & specified sublimits AFB - PM: R6552, AD: R4164, C: R1548 Any GP, Specialist. 10% credit to AFB for use of Network Providers Subject to MSA, AFB and ATB - unlimited in ATB 200% - Subject to MSA, AFB & ATB. ATB limit: R3785 p/f Subject to MSA, AFB & ATB. ATB limit: R3150 p/f R180 per script, limited to: Single R840, Family R1190 Subject to AFB - Consultations unlimited in ATB Subject to AFB limit Subject to AFB limit and Formulary R145 per script, limited to: Single R595, Family R955 R3785 p/f, Subject to MSA, AFB and ATB Combined with In-hospital limit Combined with Radiology benefit Subject to AFB limit Combined with In-hospital limit Subject to AFB limit Subject to MSA, AFB and ATB - Unlimited Subject to MSA and AFB - R14 575 p/b sublimit Subject to AFB limit, thereafter unlimited Subject to AFB limit: Limited to R6 360 p/b. No implants MSA & AFB, 2 consultations p/b per annum Subject to MSA and ATB - R3 785 p/b Combined with Lenses benefit, R1910 sublimit Included in Lenses benefit limit MSA & AFB, 1 consultation p/b per annum Subject to AFB limit, sublimit of R1700 Combined with Lenses benefit, R900 sublimit Included in Lenses benefit limit Subject to MSA, AFB and ATB - R2530 limit p/f Subject to MSA and ATB - R13 885 limit p/f Subject to MSA and ATB - R4155 limit p/f Unlimited, registration recommended Subject to AFB limit : R2 530 p/b Subject to AFB limit : R5 280 p/b sublimit Subject to AFB limit : R1 545 p/b sublimit Unlimited, registration recommended December 31, 2013 Scheme - 12 610 Pinnacle Options - 1 134 Universal Healthcare Administrators (Pty) Ltd Average age- 37.1(47.5); Pensioner %- 12.7%(22.8%) 42.10% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% December 31, 2013 Scheme - 12 610 Symmetry Options - 2 721 Universal Healthcare Administrators (Pty) Ltd Average age- 37.1(39.8); Pensioner %- 12.7%(15.4%) 42.10% 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% N/a N/a N/a N/a Salary Brackets All All All Principal Member 4412 3780 2640 Principal Member + Spouse 7847 6722 4695 Principal + Spouse + 1 Child 9072 7778 5441 Principal + Spouse + 2 Children 10297 8834 6187 Principal + Spouse + 3 Children 11522 9890 6933 E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail. Benefits Symmetry ED - 2015 Plan Type Traditional limited Plan Operation - Hospitalisation 100% of Agreed Tariff - Day-to-day Limited to AFB ( Annual Flexi Benefit - AFB) Overall Annual Maximum Unlimited Hospital Benefit 1 Private Hospital Care Netcare hospitals only/ 30% co-pay with R5000 minimum at others (except emergencies) 2 Co-payment Certain procedures, Endoscopies and Scans (R1000 to R4000) 3 Oncology Unlimited. Protocols apply. R112 360 for Biological agents (25% co-pay) 4 Organ Transplants Limited to PMB conditions at DSP 5 Dialysis Limited to PMB conditions at DSP 6 Maternity - Natural Birth Limited to 3 days and 2 nights - Elective Ceasarean Limited to 4 days and 3 nights 7 To take home medication Limited to 7 days supply per event 8 Psychiatric Hospitalisation DSP. 21 days p/f. Rehabilitation for PMB's only Radiology/Pathology/Prosthesis 1 Basic Radiology Unlimited, subject to protocols 2 MRI, CT & PET Scans Limited to R15 170 per family 3 Pathology Limited to R25 165 p/f, unless otherwise authorised 4 Internal Prosthesis Protocols and various limits apply 5 External R13 260 p/f, subject to sublimits, paid from Risk Appliances/Prosthesis Sub Acute Facilities 1 Hospice Unlimited, case management/protocols/pre-auth. 2 Nursing MSA & AFB apply, in lieu of hospitalisation 3 Ambulance Services Unlimited Chronic Benefit 27 CDL chronic conditions Unlimited - DSP (Mediscor) and Formulary applies Additional chronic conditions 19 Conditions - M R3 785, M1+ R5 670. CDL initially paid from here Day-to-day Benefit Overall Annual Maximum AFB - PM: R6552, AD: R4164, C: R1548 Preferred Provider Any GP, Specialist. 10% credit to AFB for use of Network Providers Medical Savings Account N/a Annual Threshold N/a Self Payment Gap N/a Above Threshold Benefit N/a GP's and medication 1 General Practitioners Subject to AFB - Consultations unlimited in ATB 2 Specialists Subject to AFB limit 3 Prescribed Medication Subject to AFB limit and Formulary 4 Pharmacy Advised Medicine R145 per script, limited to: Single R595, Family R955 Radiology & Pathology 1 Basic Radiology Subject to AFB limit 2 MRI, CT & PET Scans Combined with In-hospital limit 3 Pathology Subject to AFB limit Dental Benefit 1 Conservative Dentistry Subject to AFB limit, thereafter unlimited 2 Specialised Dentistry Subject to AFB limit: Limited to R6 360 p/b. No implants Optical Benefit 1 Examination MSA & AFB, 1 consultation p/b per annum 2 Lenses Subject to AFB limit, sublimit of R1700 3 Frames Combined with Lenses benefit, R900 sublimit 4 Contact Lenses Included in Lenses benefit limit Auxilliary Services 1 Physiotherapy Subject to AFB limit : R2 530 p/b 2 Psychiatry Subject to AFB limit : R5 280 p/b sublimit 3 Psychology Subject to AFB limit : R1 545 p/b sublimit HIV / AIDS Unlimited, registration recommended Financial and Demographic 1 Date of information December 31, 2013 2 Principal Members Scheme - 12 610 Symmetry Options - 2 721 3 Administrator Universal Healthcare Administrators (Pty) Ltd 4 Scheme (Option) age profile Average age- 37.1(39.8); Pensioner %- 12.7%(15.4%) 5 Solvency ratio 42.10% 6 Past Scheme increases 2012- 7.9%, 2013- 6.9%, 2014- 7.7%, 2015- 8.9% Contributions Salary Brackets All Principal Member 2217 Principal Member + Spouse 3942 Principal + Spouse + 1 Child 4569 Principal + Spouse + 2 Children 5196 Principal + Spouse + 3 Children 5823 E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail.
