Spectramed Capri 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:
Capri
Quick Overview
Main: Adult: Child:
Total Cost pm: R2,213 R1,802 R1,005

Savings: R2,388 R1,944 R1,080
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Capri
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:
  • R1,500 co-payment and limited to R9,600 per family
  • Co-payment paid
  • Sublimit increased as necessary, for approved procedures
  • No benefit for exclusions
  • Out of hospital, co-payment and sublimit increase is for MRI and CT scans only
Supplementary Services: (Physio, etc)
  • Physio: R4,100 per family
  • Sublimit increased as necessary
Transplants:
  • R350,000 per family
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Sublimits increased as necessary
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
  • Co-payments paid by you or your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • No benefit
Casualty:
  • Paid from day-to-day benefit
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • N/A
  • N/A
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.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Capri
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R2,388 R1,944 R1,080
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:
  • 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
Childcare:
  • No extra benefit available
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

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

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MATERNITY BENEFITS:
Capri
Scheme Benefits Gap benefits
Hospital stay:
  • DSP only
  • Caesarean: R10,500 limit if not authorised
  • Home births: R11,000
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

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

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CANCER (ONCOLOGY):
Capri
Scheme Benefits Gap benefits
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

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

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DENTISTRY:
Capri
Scheme Benefits Gap benefits
Dentistry:
  • Paid from day-to-day benefit
  • In-hospital: fees charged by dentist from day-to-day benefit
Orthodontics:
  • Paid from day-to-day benefit
  • No extra benefit available
Maxillo Facial Surgery: 2018 benefits coming soon. 2017 benefits:
  • Paid from day-to-day 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

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MEDICATION:
Capri
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:
  • 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

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

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OPTOMETRY:
Capri
Scheme Benefits Gap benefits
Optometry:
  • R1,300 per person every 2 years
  • Frame sublimit: R890
  • Paid from day-to-day 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

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MENTAL HEALTH:
Capri
Scheme Benefits Gap benefits
In-hospital:
  • R17,600 per family, at DSP only
Out-of-hospital:
  • Paid from day-to-day benefit
Trauma:
  • No benefit

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

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OTHER BENEFITS:
Capri
Scheme Benefits Gap benefits
General Appliances:
  • PMBs only
  • 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

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WELLNESS/PREVENTATIVE BENEFITS:
Capri
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered, with overall R1,600 per familylimit, shared with most 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 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

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

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PROSTHETICS:
Capri
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