Spectramed Cobalt medical aid plan: 2017

Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or 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: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

Compare with these plans:
Hospital Choice:
  • Unlimited, but a Designated Service Provider must be used for many benefits
Specialised Radiology:
  • R1,500 co-payment from second scan and limited to R20,700 per family
Supplementary Services: (Physio, etc)
  • Physio: R11,100 per family
Transplants:
  • Covered
Co-payments:
  • Dental in-hospital: R1,500 co-payment
  • Gastroscopy, Colonoscopy: R1,500 co-payment if in hospital
  • Sigmoidoscopy: R1,500 co-payment
  • Arthroscopy: R1,500 co-payment
  • Reflux surgery, Joint replacement and spinal surgery: R1,000 co-payment
  • Non-surgical admissions: R1,000 co-payment
Alternatives to hospitals:
  • Nursing and hospice: R13,600 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: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

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:
  • R20,700 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: R10,000 limit if not authorised
  • Home births: R13,000
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

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: covered
  • Biological and target therapies: R250,000 per family with 20% 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: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

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 =R6,800, M1 =R8,500, M2 =R10,200, M3 =R11,950, M4+ =R13,650 with further sub-limits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

Compare with these plans:

Benefit Boosteris paid by scheme and applies to out-of-hospital mental health, specialised dentistry, optometry, appliances and preventative benefits. Limits: M= R8,900; M1 =R10,800; M2= R12,200; M3 =R14,900 and M4+ =R16,700
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above

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MEDICATION:
Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 13 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

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:
  • R3,000 per person subject to benefit Booster limit
  • Paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R28,300 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

Compare with these plans:


Benefit Boosteris paid by scheme and applies to out-of-hospital mental health, specialised dentistry, optometry, appliances and preventative benefits. Limits: M= R8,900; M1 =R10,800; M2= R12,200; M3 =R14,900 and M4+ =R16,700
Out-of-hospital:
  • R6,300 per family, subject to Benefit Booster limit

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OTHER BENEFITS:
General Appliances:
  • Subject to authorisation and Benefit Booster limit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

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 R2,500 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: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered, with R2,500 per person and further sub limits for all preventative benefits
Child Immunisation:
Pap Smear:
  • Covered, with R2,500 per person and further sub limits for all preventative benefits
Mammogram:
  • Covered, with R2,500 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: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

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