Spectramed Aqua medical aid plan: 2017

Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB. Pay for all children.

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: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Unlimited, but a Designated Service Provider must be used for many benefits
Specialised Radiology:
Supplementary Services: (Physio, etc)
  • Physio: R2,250 per family
Transplants:
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

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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:
Hospital stay:
  • DSP only
  • Caesarean: R10,000 limit if not authorised
  • Home births: R5,200
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Consultations:
  • 10 prenatal consults with midwife
  • 3 postnatal consults with midwife
  • Antenatal classes: R500 per family
Scans:
  • No benefit

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • Chemo and radiotherapy: Subject to protocol
  • Biological and target therapies: PMBs only
  • 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: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • No benefit, unless PMB
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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

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MEDICATION:
Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No 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

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OPTOMETRY:
Optometry:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • PMBs only, 21 days per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • No benefit

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OTHER BENEFITS:
General Appliances:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
HIV:
  • Includes post exposure prophylaxis and mother-to-child transmission
Emergency Transport:
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered, with R350 per family sublimit for all preventative benefits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered, with R350 per family sublimit for all preventative benefits
Child Immunisation:
Pap Smear:
  • Covered, with R350 per family sublimit for all preventative benefits
Mammogram:
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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