Compcare Pinnacle ED: in-and-out of hospital benefits (2022)

This page shows the In-hospital, Out-of-hospital and Medicine benefits for Compcare Pinnacle ED.

Pricing:

Pinnacle ED - Jan 2022 prices
Main member: Adult member: Child member:
Total Cost pm: R6,535 R5,085 R1,820
(Pay only for first 3)
Savings: R15,684 R12,204 R4,368
Extended Fund: R3,624 R2,820 R1008
Self Payment Gap:
R3,300 R2,280 R684
Above Threshold: R9,732 per person
R19,920 per family
Children Rates:
  • Under 21 yrs, unless student or financially dependent. Then, under 27yrs.
  • (Pay only for first 3)
Note:
  • Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
  • All treatments and procedures are subject to authorisation and protocols
  • All benefits are listed as an indication only. Please verify with your broker and scheme
View other benefits:
Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics

You can also:
Compare any two plans, side by side | View all the Compcare plans, with costs and brief summary

In-hospital Procedures: (2021 benefits)

x
Pinnacle ED
non-Network Specialists:
  • Up to 200% scheme rate
network Specialists:
  • Up to 200% scheme rate
non-Network GPs:
  • Up to 100% scheme rate
network GPs:
  • Up to 200% scheme rate
Hospital Choice:
  • Choose any Netcare hospital
Penalty for using other hospital:
  • 30% penalty, with a R7,500 minimum
Specialised Radiology:
  • MRI, CT and PET Scans: Unlimited
  • R2,500 co-payment, unless PMB
  • No benefit for screening purposes
  • In and out of hospital
Supplementary Services: (Physio, etc)
  • R10,500 per family, in and out of hospital
Transplants:
  • PMBs only
Dialysis:
  • PMBs only
Day Hospitals:
  • No specific requirements for day hospital use are listed
Co-payments:
    • Annual Limit for minor non-PMB elective procedures: R55,000
Alternatives to hospitals:
  • Home nursing: 60 days per family
  • Step-down nursing, hospice and rehab: as authorised
Casualty:
  • ER visits as a result of physical injury caused by an external force: paid in full by scheme
  • ER visits that result in admission: paid by scheme
  • One visit per child under 6 yrs: R1 250
Other:
  • Surgical procedures out of hospital: Unlimited
  • Aviation medical examinations: Covered
  • Treatment for injuries due to extreme sports are covered
  • Internal nerve stimulators:R120,000
Note:
  • PMBs: Prescribed Minimum Benefits. You can read more about PMBs, see a list of all PMB conditions or read more what "PMB only" benefit means.
  • DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
  • Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
  • Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones here, but you must consult with your scheme to get the full list.
View other benefits:
Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics

You can also:
Compare any two plans, side by side | View all the Compcare plans, with costs and brief summary

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.


Out-of-hospital Procedures: (2021 benefits)

Pinnacle ED
Summary of day-to-day benefits:
Main Member: Adult: Child:
Savings /yr: R15,684 R12,204 R4,368
Extended Fund: R3,624 R2,820 R1008
Self Payment Gap:
R3,300 R2,280 R684
Above Threshold: R9,732 per person
R19,920 per family
PMBs out of hospital:
  • All medical aids must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
  • This can include consults with specialists, blood or other tests, radiology and medicine
  • The benefit is paid by the scheme, and not out of your savings account
  • If you have no day-to-day funds, you still have cover for PMBs
  • Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
  • See our Guide to PMBs for more information.
General info:
    Claims are first paid Savings Account, then from Fund (AFB). When this si finished, member pays self-payment gap out of pocket. During this period, claims will accumulate to the annual threshold at the scheme rate. Once the annual threshold is reached, specific Above Threshold Benefits (ATB) will be available up to a limit of R9,732 per person and R19,920 per family
GP consultations:
  • From day-to-day benefit
Childcare:
  • Baby Wellness visits: 2 per year, for 4m-18m
  • Unlimited GP consultations and basic dentistry for children under 6yrs
  • Initial Occupational Therapy consultation
  • School readiness assessments
  • Kid’s active benefit assessment and exercise prescription programme
  • Kid’s nutritional benefit assessment and healthy eating programme
Specialists consultations:
  • From day-to-day benefit
Pathology:
  • From day-to-day benefits
General radiology:
  • From day-to-day benefits
Specialised radiology:
  • MRI, CT and PET Scans: Unlimited
  • R2,500 co-payment, unless PMB
  • No benefit for screening purposes
  • In and out of hospital
Supplementary Services: (Physio, etc)
  • Speech therapists, social workers, podiatrists, occupational therapists, homeopaths and naturopaths, dietitians, chiropractors (X-rays excluded), audiologist, physiotherapy and biokinetics in-and-out of hospital: R11,000 per family from day to day benenfit
General Appliances:
  • R34,900, from day-to-day benefit
1.1. Hearing Aids:
  • R23,000, from day-to-day benefit, every 3 years
1.2. Wheelchairs:
  • See above
Note:
  • PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
  • DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
  • Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
View other benefits:
Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics

You can also:
Compare any two plans, side by side | View all the Compcare plans, with costs and brief summary

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.


Medication cover: (2021 benefits)

Pinnacle ED
Summary of day-to-day benefits:
Main Member: Adult: Child:
Savings /yr: R15,684 R12,204 R4,368
Extended Fund: R3,624 R2,820 R1008
Self Payment Gap:
R3,300 R2,280 R684
Above Threshold: R9,732 per person
R19,920 per family
Chronic:
  • Additional 47 conditions, paid from from day-to-day benefit
Acute (presrcibed) medication:
  • From day-to-day benefit
Over-the-counter:
  • R250 per script
  • No sublimit in savings
  • R1,100 per person and R1,600 per family from fund
  • Does not accumulate to threshold
Birth Control:
  • R2,950 per person, including devices
On Discharge:
  • 7 days per admission
Biological:
  • R310,000 per family
Note:
  • Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
  • Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
  • PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
  • DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
  • Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
View other benefits:
Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics

You can also:
Compare any two plans, side by side | View all the Compcare plans, with costs and brief summary

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.

Important!

  • Unless specified, assume that all benefits are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • "Unlimited" benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised

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