Spectra Azure is regarded as Spectramed’s most popular option, as it offers unlimited in-hospital tariff coverage, plus dentistry and other day-to-day expenses. As a prime choice in providing value-for-money benefits, it is ideal for the young family with youngsters that are seeking adequate, yet affordable cover.
Who should choose this option?
- The established family with busy youngsters
- The family that takes their healthcare needs seriously and who want to make proper provision for their growing medical needs
- People looking for unlimited hospital cover, an extensive savings account for day-to-day medical costs (My Saver™), cover for 29 chronic conditions and an additional 7 CDL+ conditions
- Members who require additional benefits such as the Benefit Booster™ (Psychiatric treatment, substance & alcohol abuse and associated conditions; Screening benefit; MediBooster; and Specialised Dentistry), which does not affect their My Saver™
- Those looking for comprehensive preventative care
Contributions
| Monthly Income | Membership | Monthly Risk | Monthly Saving | Total Contribution |
|---|---|---|---|---|
| R0 – R8 000 | ||||
| Principal Member | R3 100 | R658 | R3 758 | |
| Adult Dependant | R1 747 | R370 | R2 117 | |
| Child Dependant 1 | R935 | R198 | R1 133 | |
| Child Dependant 2 | R629 | R133 | R762 | |
| Child Dependant 3 | R428 | R91 | R519 | |
| R8 001 – R11 500 | ||||
| Principal Member | R3 221 | R683 | R3 904 | |
| Adult Dependant | R2 057 | R436 | R2 493 | |
| Child Dependant 1 | R1 045 | R222 | R1 267 | |
| Child Dependant 2 | R858 | R182 | R1 040 | |
| Child Dependant 3 | R618 | R131 | R749 | |
| R11 501+ | ||||
| Principal Member | R3 328 | R706 | R4 034 | |
| Adult Dependant | R2 386 | R506 | R2 892 | |
| Child Dependant 1 | R1 169 | R248 | R1 417 | |
| Child Dependant 2 | R1 134 | R240 | R1 374 | |
| Child Dependant 3 | R1 134 | R240 | R1 374 |
* You only pay for a maximum of 3 children
Hospital Benefit
- The Overall Annual Limit (OAL) for Spectra Cobalt is unlimited
- All Hospital events MUST be authorised:
- A non-emergency case at least 48 hours prior to admission
- In case of an emergency, authorisation no later than 48 hours after admission
- Please note, for after-hours emergency medical assistance, contact 0800 773 2872
- 20% Penalty (min R3 000) if not pre-authorised
- All in-Hospital benefits will be covered at 100% of Spectra Tariff
- Organ Transplants require registration on a Benefit Management Programme (BMP), as well as making use of a Designated Service Provider (DSP)
- The member must make use of the Spectra High Formulary for anti-rejection medication
- The member must make use of the DSP for anti-rejection medication, otherwise a 40% penalty will apply
- All Prescribed Minimum Benefits (PMBs) will be covered at 100% of Cost at a DSP ONLY. Where treatment is voluntarily obtained from a non-DSP in non-emergency cases, a 30% penalty will apply.
| Overall Annual Limit (OAL) | Unlimited |
| Dental / Oral Surgery Related, General Anaesthesia & Intravenous Sedation | Certain exclusions apply (refer to www.spectramed.co.za for exclusions) Professional fees charged by a dental practitioner in-hospital subject to Benefit Booster™ |
| General Hospitalisaion | In-Hospital co-payments: These procedures are subject to the following co-payments:
|
| Internal Prostheses | Limit = R120,000 per family. Subject to pre-authorisation and clinical motivation. Subject to “Fit for Surgery” certification.Limit: 2x spinal levels per beneficiary per annum. Sub-limits: Spinal: R42 000 (both levels).Limit: 1x joint replacement per beneficiary per annum. Sub-limits: Knee and Hip replacement: R42 000 (includes cement). |
| Maternity | Home births subject to R11 000 per confinement. Must be registered on Maternity Programme. Antenatal classes subject to R525 per family. If not authorised, a R10 500 limit will apply to Caesarean Sections.
Out-of-Hospital benefit Some of these benefits form part of your preventative care benefits |
| Organ Transplants & Anti-rejection Medication | Sub-limit = R500 000 per family. Registration for organ transplants and anti-rejection medication must be done through the third-party service provider |
| Pathology | 100% of Spectra Tariff |
| Physiotherapy | Sub-limit = R5 800 per family |
| Psychiatric Treatment, Substance & Alcohol Abuse & Associated Conditions | Sub-limit = R18 500 per family |
| Radiology | 100% of Spectra Tariff |
| Take-Home Medicine | 5 days post-hospitalisation |
Major Medical
- Pre-authorisation is required for ALL Major Medical events/benefits. Certain limits apply. Please see relevant benefits applicable rates
- 20% Penalty (min R3 000) if not pre-authorised
- Oncology treatment requires pre-authorisation and registration with the Oncology third-party service provider. (Subject to the Standard and Referral Protocol)
- Oncology treatment requires the utilisation of the DSP oncologist, otherwise a 30% penalty will apply
- The member must make use of the Spectra High Formulary for oncology medication
- The member must make use of the DSP for oncology medication, otherwise a 40% penalty will apply
- HIV/AIDS and Diabetes Treatment requires pre-authorisation and the member must be enrolled on the Scheme HIV/AIDS/Diabetes DSP and Management Programme. Where services for HIV/AIDS and Diabetes are voluntarily obtained from a non-DSP, a 30% penalty will apply
- The member must make use of the Spectra High Formulary for HIV/AIDS and Diabetes medication
- The member must make use of the DSP for HIV/AIDS and Diabetes medication, otherwise a 40% penalty will apply
- All PMBs will be covered at 100% of Cost at a DSP ONLY. Where treatment is voluntarily obtained from a non-DSP in non-emergency cases, a 30% penalty will apply
- Please note that all medication used in the treatment of a registered PMB or CDL condition is subject to a DSP and the Spectra High Formulary
- The use of a non-DSP for medication is subject to a 40% penalty
| Prescribed Minimum Benefits (PMBs) | Limited to statutory algorithms and protocols for treatment |
| Disease Management HIV/AIDS & related illnesses | Included in this benefit: HIV+ members, PEP (Post Exposure Prophylaxis) and MTC (Mother To Child transmission). This benefit is unlimited. |
| Diabetes | Included in this benefit: Baseline and monitoring tests as per protocols only. |
| Non-HIV+ Members: Pathology (VCT) |
Only 2x diagnostic tests per beneficiary per annum. More than 2 tests per annum require a motivation from healthcare practitioner and use of a DSP.
|
| In-Hospital Diabetes, HIV/AIDS & related illnesses |
Unlimited |
| Out-of-Hospital Diabetes, HIV/AIDS & related illnesses |
Unlimited |
| Prescribed Medication Diabetes, HIV/AIDS & related illnesses |
Unlimited Registration for prescribed medication must be done through the third-party service provider |
| Pathology Diabetes, HIV/AIDS & related illnesses |
Protocols apply. Baseline monitoring tests as per protocols only |
| Other Out-of-Hospital Expenses Diabetes, HIV/AIDS & related illnesses |
Protocols apply. 100% of cost at DSP. |
| Ambulance Services & Inter-hospital ambulance transfers | Unlimited – 100% Spectra Tariff Must be obtained from Scheme preferred provider and certified as essential by Medical Practitioner |
| Blood Transfusions | Unlimited – 100% of Spectra Tariff at DSP |
| Dialysis | 100% of Spectra Tariff. Treatment available from DSP only, otherwise a 30% penalty will apply. |
| Investigative & surgical procedures in consulting rooms | Unlimited – 200% Spectra tariff
Including, but not limited to:
|
| Nursing Services & Hospice | Sub-limit – R8 600 per family 100% of Spectra tariff |
| Chemotherapy, Radiotherapy | Sub-limit = R520 000 per family. Limited to 1 x PET scan per annum for “staging” and subject to annual Specialised Radiology benefit. 100% of Spectra Tariff. |
| Biological & Targeted Therapy Entities | Sub-limit = R210 000 per family. 25% levy applicable. 100% of Spectra Tariff. |
| Specialised Radiology (MRI / CT / PET / Bone Density & Radio-isotope Scans) |
MRI and CT Scans: R1 500 co-payment will apply from 1st scan per annum. Sub-limit = R15 700 per family. 100% of Spectra Tariff |
CDL Medication (Chronic Disease List)
- The Chronic Benefit requires the member to be registered for Chronic Disease List (CDL), and this must be reviewed annually. Claims for the diseases listed on the CDL will be covered at 100% of Cost. Registration for chronic conditions must be done through the third-party service provider
- The member must make use of the Spectra High Formulary for CDL medication
- The member must make use of the DSP for CDL medication, otherwise a 40% penalty will apply
| Chronic Disease List (CDL) | |
|---|---|
| Biological Entities | Subject to pre-authorisation and clinical motivation. 30% Levy applicable. Sub-limit = R40 000 per family. 100% of Spectra Tariff |
| CDL 1 | Addison’s Disease |
| CDL 2 | Asthma |
| CDL 3 | Bipolar Mood Disorder |
| CDL 4 | Bronchiectasis |
| CDL 5 | Congestive Cardiac Failure |
| CDL 6 | Cardiomyopathy |
| CDL 7 | Chronic Renal Disease |
| CDL 8 | Chronic Obstructive Pulmonary Disease |
| CDL 9 | Coronary Artery Disease |
| CDL 10 | Crohn’s Disease |
| CDL 11 | Diabetes Insipidus |
| CDL 12 | Diabetes Mellitus – Type 1 |
| CDL 13 | Diabetes Mellitus – Type 2 |
| CDL 14 | Dysrhythmias |
| CDL 15 | Epilepsy |
| CDL 16 | Glaucoma |
| CDL 17 | Haemophilia |
| CDL 18 | Hyperlipidaemia |
| CDL 19 | Hypertension |
| CDL 20 | Hypothyroidism |
| CDL 21 | Multiple Sclerosis |
| CDL 22 | Parkinson’s Disease |
| CDL 23 | Rheumatoid Arthritis |
| CDL 24 | Schizophrenia |
| CDL 25 | Systemic Lupus Erythematosus (SLE) |
| CDL 26 | Ulcerative Colitis |
| CDL 27 | HIV/AIDS |
| CDL 28 | Benign Prostate Hyperplasia |
| CDL 29 | Hormone Replacement Therapy (Menopause) |
My Saver™
- All My Saver™ benefits will be paid for at 100% of Spectra Tariff
- These benefits are all subject to the 2018 My Saver™ limit. Once this savings balance is depleted, the member will no longer have access to these benefits for the remainder of 2018
- CDL+ is the extended chronic disease list. The member must be registered for this and this must be reviewed annually
- Registration for CDL+ conditions must be done through the third-party service provider. Claims for the diseases listed on the CDL+ will be covered from the My Saver™ limit
- The member’s My Saver™ funds remain their money, even when they leave the Scheme. Any unused funds that remain at year-end will be carried over to the following year.
| Acute Medication | 100% of Spectra Tariff |
| Allied Health Services | Includes all services as obtained from a registered Allied Health Services professional.100% of Spectra Tariff. |
| Conservative Dentistry | 100% Spectra tariff
Including, but not limited to:
|
| Extended Chronic Medication (CDL+) | 100% of Spectra Tariff. Subject to protocols as defined in Scheme rules. The CDL+ for Spectra Cobalt is made up of:
|
| External Prostheses & Appliances | Subject to pre-authorisation and clinical motivation and registration with the preferred provider. 100% of Spectra Tariff |
| General Practitioner (GP) Consultations & associated costs | 100% Spectra tariff |
| Medical Specialists | 100% Spectra tariff – Consultations & Procedures |
| Optical | 100% of Spectra Tariff. Optical Sub-limit = R2 400 per beneficiary. Frame sub-limit = R1 100 per beneficiary (included in optical sub-limit). Benefit available every 2 years from date of treatment for frames and lenses (per beneficiary).Specific exclusions:
|
| Pathology | 100% Spectra tariff |
| Pharmacy-Advised Therapy (PAT) | 100% Spectra tariff |
| Physiotherapy | 100% Spectra tariff |
| Radiology | 100% Spectra tariff. Excludes: Specialised Radiology (refer Specialised Radiology benefit) |
Benefit Booster™
- The Benefit Booster™ benefits will be paid for at 100% of Spectra Tariff. Note that certain sub-limits apply
- These benefits are all subject to the 2018 Benefit Booster™ limit. Once this benefit is depleted, the member will no longer have access to these benefits for the remainder of 2018.
| Benefit Booster™ | M+0 = R7 100; M+1 = R8 600; M+2 = R9 900; M+3 = R11 300; M+4+ = R12 700 100% of Spectra tariff |
| Psychiatric treatment, substance & alcohol abuse and associated conditions | Subject to PMBs Sub-limit = R5 500 per family |
| Preventative & Screening Benefit | 100% of Spectra Tariff. Sub-limit = R1 500 per beneficiary. Subject to preferred provider only.Covers 1 test per beneficiary per annum for each of the following:
Covers 1 test per beneficiary every two years for:
This forms part of your preventative care benefits |
| MediBooster | 100% of Spectra Tariff. Sub-Limit = R1 600 per family. Subject to registration and Self-Health Assessment. Only available through Preferred Provider. This forms part of your preventative care benefits |
| Specialised Dentistry | Specialised Dentistry sub-limits are:
M+0 = R5 250; M+1 = R6 600; M+2 = R7 850; M+3 = R9 250; M+4 = R10,600 Including, but not limited to:
Uniform application of Specialised Dentistry benefits applied to:
This forms part of your preventative care benefits. |
Preventative Care
- The Benefit Booster™ benefits will be paid for at 100% of Spectra Tariff. Note that certain sub-limits apply
- Where applicable benefits are all subject to the 2018 Benefit Booster™ and My Saver™ limits. Once this benefit is depleted, the member will no longer have access to these benefits for the remainder of 2018
- Certain of these benefits are subject to Hospital Benefit, please refer to this section for specific applicable limits.
| Preventative & Screening Benefit | 100% of Spectra Tariff. Sub-limit = R1 500 per beneficiary. Subject to preferred provider only.Covers 1 test per beneficiary per annum for each of the following:
Covers 1 test per beneficiary every two years for:
Subject to Benefit Booster™ limit |
| Clinic Nursing Consultations | 30 Minute consultation – 1 consultation per beneficiary per year. 15 Minute consultation – 2 consultations per beneficiary per year. Subject to preferred provider only. Subject to Benefit Booster™ limit. |
| Clinic Nursing Consultations (Additional consultations earned when having the Flue Vaccine) |
15 Minute consultation – 2 consultations per beneficiary per year. Subject to preferred provider only. Subject to Hospital Benefit. |
| Maternity Ante-natal classes |
R525 per family. Subject to Hospital Benefit. |
| Maternity Pre-natal visits / consultations (GP or Gynaecologist) |
Visits paid from My Saver™ |
| Maternity Visits / Consultations (Midwife) |
10x Pre-natal midwife visits 3x Post-natal midwife visits Subject to Hospital Benefit |
| Maternity Scans | 3x 2D scans. Subject to Hospital Benefit. |
| Mother Ante-natal Consultations | 1x consultations per beneficiary per year. Subject to preferred provider only. Subject to Benefit Booster™ limit |
| Well Baby Consultations | 1x consultation per beneficiary per year, including administering of immunisations. Cost of vaccine covered by applicable PMB protocol. Subject to preferred provider only. Subject to Benefit Booster™ limit |
| MediBooster | 100% of Spectra Tariff. Sub-limit R1 600 per family. Subject to registration and Self-Health Assessment. Only available through Preferred Provider. Subject to Benefit Booster™ limit. |
