Spectramed Cyan A medical aid plan: 2017

Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB. Pay for maximum 3 children. Income-limited plan: R0-R8,000pm only

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:
Hospital Choice:
  • Unlimited, but a Designated Service Provider must be used for many benefits
Specialised Radiology:
  • R1,500 co-payment and limited to R4,500 per family
Supplementary Services: (Physio, etc)
  • Physio: R2,780 per family
Transplants:
  • R200,000 per family
Co-payments:
  • Dental in-hospital: R2,500 co-payment
  • 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
Alternatives to hospitals:
  • No benefit

.
.

OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Gastroscopies, colonoscopies, plantar wart removal, removal of ingrown toenail, varicose vein injection/drainage: paid by scheme
  • Otherwise, from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:

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:
  • R4,500 per family with a R1,500 co-payment
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

.
.

MATERNITY BENEFITS:
Hospital stay:
  • R12,000 unless at DSP
  • Caesarean: R10,500 limit if not authorised
  • Home births: R5,800
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:

Consultations:
  • 10 prenatal consults with midwife
  • 3 postnatal consults with midwife
  • Antenatal classes: R500 per family
Scans:
  • Paid from day-to-day benefit

.
.

CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • Chemo and radiotherapy: R116,000 per family
  • Biological and target therapies: R100,000 per family with 30% co-payment
  • DSP oncologist only

Note: 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.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:

.
.

DENTISTRY:
Dentistry:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:

Orthodontics:
  • Paid from day-to-day benefit
Maxillo Facial Surgery:
  • Paid from day-to-day benefit

.
.

MEDICATION:
Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 2 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:
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
Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

.
.

OPTOMETRY:
Optometry:
  • M =R720, M1 =R1,060, M2 =R1,290, M3 =R1,560, M4+ =R1,900
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:

.
.

MENTAL HEALTH:
In-hospital:
  • R6,700 per family, at DSP only
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:


Out-of-hospital:
  • Paid from day-to-day benefit

.
.

OTHER BENEFITS:
General Appliances:
  • Subject to authorisation
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:

1.1. Hearing Aids:
1.2. Wheelchairs:
Dialysis:
HIV:
  • Includes post exposure prophylaxis and mother-to-child transmission
Emergency Transport:
International Coverage:
Other:

.
.

WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered, with R1,000 per family and further sub limits for all preventative benefits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered, with R1,000 per family and further sub limits for all preventative benefits
Child Immunisation:
Pap Smear:
  • Covered, with R1,000 per family and further sub limits for all preventative benefits
Mammogram:
PAS Test:
HIV Test:

.
.

PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

Compare with these plans:
Sub-limits:

    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