Spectramed Azure C medical aid plan: 2017

Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB. Pay for max 3 children, with 2nd and 3rd child=R1,175pm . Income-limited plan: R11,500+pm 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: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

Compare with these plans:
Hospital Choice:
  • Unlimited, but a Designated Service Provider must be used for many benefits
Specialised Radiology:
  • R1,500 co-paymentand limited to R14,600 per family
Supplementary Services: (Physio, etc)
  • Physio: R5,550 per family
Transplants:
  • R500,000 per family
Co-payments:
  • Dental in-hospital: R2,000 co-payment
  • Gastroscopy, Colonoscopy: R1,500 co-payment if in hospital
  • Sigmoidoscopy: R1,500 co-payment
  • Hysterectomy: R1,500 co-payment
  • Laparoscopy, hysteroscopy, endometrial ablation: R2,000 co-payment
  • Arthroscopy: R1,000 co-payment
  • Reflux surgery: R2,000 co-payment
  • Joint replacement and spinal surgery: R4,500 co-payment
  • Non-surgical admissions: R1,000 co-payment
Alternatives to hospitals:
  • Nursing and hospice: R8,200 per family

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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: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

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:
  • R14,600 per family with a R1,500 co-payment
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
  • DSP only
  • Caesarean: R10,500 limit if not authorised
  • Home births: R11,000
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

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

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • Chemo and radiotherapy: R500,000 per family
  • Biological and target therapies: R200,000 per family with 25% 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: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: paid by scheme subject to Benefit Booster benefit, up to M =R5,900, M1 =R6,300, M2 =R7,500, M3 =R8,800, M4+ =R10,100 with further sub-limits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

Compare with these plans:

Benefit Boosteris paid by scheme and applies to out-of-hospital mental health, specialised dentistry and preventative benefits. Limits: M= R6,800; M1 =R8,200; M2= R9,450; M3 =R10,800 and M4+ =R12,100
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above

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MEDICATION:
Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 4 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

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

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OPTOMETRY:
Optometry:
  • R2,300 per person every 2 years
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R17,600 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

Compare with these plans:


Benefit Boosteris paid by scheme and applies to out-of-hospital mental health, specialised dentistry and preventative benefits. Limits: M= R6,800; M1 =R8,200; M2= R9,450; M3 =R10,800 and M4+ =R12,100
Out-of-hospital:
  • R5,250 per family, subject to Benefit Booster benefit

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OTHER BENEFITS:
General Appliances:
  • Subject to authorisation
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

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:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered, with R1,500 per person and further sub limits for all preventative benefits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered, with R1,500 per person and further sub limits for all preventative benefits
Child Immunisation:
Pap Smear:
  • Covered, with R1,500 per person and further sub limits for all preventative benefits
Mammogram:
  • Covered, with R1,500 per person and further sub limits for all preventative benefits
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: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

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