Spectramed Aqua medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
Aqua
Quick Overview
Main: Adult: Child:
Total Cost pm: R1,335 R1,230 R472

Savings (per year):
  • No savings option on this plan
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Aqua
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital, but all PMBs subject to DSP only or a 30% co-payment
  • DSPs include Netcare and Lifecare hospitals, among others
  • No benefit
Specialised Radiology:
  • PMBs only
  • No benefit
Supplementary Services: (Physio, etc)
  • Physio: R2,360 per family
  • Sublimit increased as necessary
Transplants:
  • PMBs only
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments:
  • Gastroscopy, Colonoscopy: R1,500 co-payment if in hospital
  • Sigmoidoscopy: R1,500 co-payment
  • Hysterectomy and reflux surgery: R3,000 co-payment
  • Laparoscopy, hysteroscopy, endometrial ablation: R2,500 co-payment
  • Procedural arthroscopy: R2,000 co-payment
  • Non-surgical admissions: R1,000 co-payment
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • No benefit
Casualty:
  • No benefit, unless PMB
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • Diagnostic arthroscopy: no benefit
  • In-hospital dentistry: no benefit
  • Reflux surgery: no benefit
  • Pathology: M =R725; M1 =R1,030; M2 =R1,200; M3 =R1,580; M4+ = R1,820
  • Standard Radiology: M =R725; M1 =R1,030; M2 =R1,200; M3 =R1,580; M4+ = R1,820
  • Blood transfusion: DSP only
  • No benefit for exclusions
  • Sublimits increased as necessary for procedures approved by medical aid
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

No phone calls!
Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

.
.
.
.
OUT OF HOSPITAL BENEFITS (non-PMB):
Aqua
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • No benefit
Childcare:
  • No extra benefit available
Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MATERNITY BENEFITS:
Aqua
Scheme Benefits Gap benefits
Hospital stay:
  • DSP only
  • Caesarean: R10,500 limit if not authorised
  • Home births: R5,250
Consultations:
  • 2 consults with GP or gynaecologist
  • 10 prenatal consults with midwife
  • 3 postnatal consults with midwife
  • Antenatal classes: R500 per family
Scans:
  • 2x 2D scans paid by scheme

No phone calls!
Our quote will include the right gap cover for this plan

.
.
CANCER (ONCOLOGY):
Aqua
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Chemo and radiotherapy: Subject to protocol
  • Biological and target therapies:PMBs only
  • DSP oncologist only

No phone calls!
Our quote will include the right gap cover for this plan

.
.
DENTISTRY:
Aqua
Scheme Benefits Gap benefits
Dentistry:
  • No benefit, unless PMB
Orthodontics:
  • You pay this out of pocket
  • No extra benefit available
Maxillo Facial Surgery:
  • No benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MEDICATION:
Aqua
Scheme Benefits Gap benefits
Chronic:
  • PMB chronic: paid by scheme. Must be obtained from DSP or 40% co-payment applies.
  • DSPs include Dischem and Clicks
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • 5 days supply
Biological:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
OPTOMETRY:
Aqua
Scheme Benefits Gap benefits
Optometry:
  • No benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

.
.
MENTAL HEALTH:
Aqua
Scheme Benefits Gap benefits
In-hospital:
  • PMBs only, 21 days per person
Out-of-hospital:
  • No benefit
Trauma:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
OTHER BENEFITS:
Aqua
Scheme Benefits Gap benefits
General Appliances:
  • No benefit
  • No benefit
1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • No benefit
  • No benefit
Dialysis:
  • DSP only, or a 30% co-payment
HIV:
  • Includes post exposure prophylaxis and mother-to-child transmission
  • No benefit
Emergency Transport: 2018 benefits are coming soon!
  • No benefit
International Insurance:
  • No benefit
  • No benefit
Other: 2018 benefits are coming soon!

No phone calls!
Our quote will include the right gap cover for this plan

.
.
WELLNESS/PREVENTATIVE BENEFITS:
Aqua
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered, with R350 per family sublimit for all preventative benefits
  • No benefit
Pneumonia vaccines: 2018 benefits are coming soon!
  • No benefit
Back Rehabilitation Programme: 2018 benefits are coming soon!
  • No benefit
Biometric Screening:
  • Covered, with R350 per family sublimit for all preventative benefits
  • No benefit
Child Immunisation: 2018 benefits are coming soon!
  • No benefit
Pap Smear:
  • Covered, with sublimits
  • No benefit
Mammogram: 2018 benefits are coming soon!
  • No benefit
PAS Test: 2018 benefits are coming soon!
  • No benefit
HIV Test: 2018 benefits are coming soon!
  • No benefit
Other:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

.
.
PROSTHETICS:
Aqua
Scheme Benefits Gap benefits
Overal Limit:
  • An additional R40,000 per sublimit, per event
Sub-limits:
  • An additional R40,000 per sublimit, per event

No phone calls!
Our quote will include the right gap cover for this plan


    Important!
  • Unless specified, assume that all benefits are paid 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