Spectramed Capri 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:
Capri
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R2,213 R1,802 R1,005
Cost 2017: (R2,003) (R1,609) (R909)
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: R2,388 R1,944 R1,080
Children:
    In 2018, this plan:
  • 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:
Capri
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:
  • R1,500 co-payment and limited to R9,600 per family
Supplementary Services: (Physio, etc)
  • Physio: R4,100 per family
Transplants:
  • R350,000 per family
Co-payments:
  • Dental in-hospital: R2,500 co-payment
  • Gastroscopy, Colonoscopy, Sigmoidoscopy: R1,500 co-payment if in hospital
  • Hysterectomy: R1,500 co-payment
  • Laparoscopy, hysteroscopy, endometrial ablation: R2,500 co-payment
  • Arthroscopy: R1,000 co-payment
  • Reflux surgery: R3,000 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:
  • Paid from day-to-day benefit
Other: 2018 benefits are coming soon!
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OUT OF HOSPITAL BENEFITS:
Capri
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Gastroscopies, colonoscopies, plantar wart removal, removal of ingrown toenail, varicose vein injection/drainage: paid by scheme at 200% scheme rate
  • Otherwise, from day-to-day benefit


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Childcare:
  • No benefit
Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology: 2018 benefits coming soon. 2017 benefits:
  • R8,900 per family with a R1,500 co-payment
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit
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MATERNITY BENEFITS:
Capri
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • DSP only
  • Caesarean: R10,500 limit if not authorised
  • Home births: R11,000

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Consultations:
  • 10 prenatal consults with midwife
  • 3 postnatal consults with midwife
  • Antenatal classes: R500 per family
  • Otherwise, from day-to-day benefit
Scans:
  • 2x 2D scans paid by scheme
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CANCER (ONCOLOGY):
Capri
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • Chemo and radiotherapy: R285,000 per family
  • Biological and target therapies: R155,000 per family with 30% co-payment
  • 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:
Capri
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • Paid from day-to-day benefit
  • In-hospital: fees charged by dentist from day-to-day benefit

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Orthodontics:
  • Paid from day-to-day benefit
Maxillo Facial Surgery: 2018 benefits coming soon. 2017 benefits:
  • Paid from day-to-day 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:
Capri
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:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • Paid from day-to-day benefit
On Discharge:
  • 5 days supply
Biological:
  • No benefit
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OPTOMETRY:
Capri
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • R1,300 per person every 2 years
  • Frame sublimit: R890
  • Paid from day-to-day benefit

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MENTAL HEALTH:
Capri
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • R17,600 per family, at DSP only

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Out-of-hospital:
  • Paid from day-to-day benefit
Trauma:
  • No benefit
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OTHER BENEFITS:
Capri
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • PMBs only
  • 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:
Capri
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered, with overall R1,600 per familylimit, shared with most 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 overall R1,600 per familylimit, shared with most preventative benefits
  • No benefit
Child Immunisation: 2018 benefits are coming soon!
  • No benefit
Pap Smear:
  • Covered, with overall R1,600 per familylimit, shared with most preventative benefits
  • No benefit
Mammogram:
  • Covered, with overall R1,600 per familylimit, shared with most preventative benefits
  • 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