Spectramed Aqua medical aid plan: 2017 vs 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
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R1,335 R1,230 R472
Cost 2017: (R1,208) (R1,099) (R427)
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Savings: No savings option on this plan
Children:
    In 2018, this plan:
  • No longer covers in-hopsital dentistry
  • No longer covers reflux surgery
  • Offers maternity consults and scans, paid by scheme

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Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family


IN HOSPITAL PROCEDURES:
Aqua
2017 v 2018 benefits Gap benefits Notes
Payout Rate for Specialists:
  • Up to 500% of scheme rate
  • In case of admission related to accident:
    • R300 per day, for days 1-13
    • R600 per day for days 14-20
    • R1,200 per day for days 21-30

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Hospital Choice:
  • Unlimited, but all PMBs subject to Designated Service Provider only or a 30% co-payment
  • DSPs include Netcare and Lifecare hospitals, among others
Specialised Radiology:
  • PMBs only
Supplementary Services: (Physio, etc)
  • Physio: R2,360 per family
Transplants:
  • PMBs only
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 covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Alternatives to hospitals:
  • No benefit
Casualty:
  • No benefit, unless PMB
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
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OUT OF HOSPITAL BENEFITS:
Aqua
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • No benefit


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Childcare:
  • No benefit
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
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MATERNITY BENEFITS:
Aqua
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • DSP only
  • Caesarean: R10,500 limit if not authorised
  • Home births: R5,250

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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
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CANCER (ONCOLOGY):
Aqua
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • Chemo and radiotherapy: Subject to protocol
  • Biological and target therapies:PMBs only
  • DSP oncologist only
All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
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DENTISTRY:
Aqua
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • No benefit, unless PMB

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Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • No benefit

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

MEDICATION:
Aqua
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • PMB chronic: paid by scheme. Must be obtained from DSP or 40% co-payment applies.
  • DSPs include Dischem and Clicks

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Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • 5 days supply
Biological:
  • No benefit
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OPTOMETRY:
Aqua
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • No benefit

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MENTAL HEALTH:
Aqua
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • PMBs only, 21 days per person

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Out-of-hospital:
  • No benefit
Trauma:
  • No benefit
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OTHER BENEFITS:
Aqua
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • No benefit
  • No benefit

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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:
  • No benefit
International Insurance:
  • No benefit
  • No benefit
Other: 2018 benefits are coming soon!
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WELLNESS/PREVENTATIVE BENEFITS:
Aqua
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered, with R350 per family sublimit for all preventative benefits
  • No benefit

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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

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

2017 v 2018 benefits Gap benefits Notes
Overal Limit:
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Sub-limits:
  • An additional R40,000 per sublimit, per event

    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