Spectra Azure Option

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:

  • Arthroscopy: R1 000
  • Dental in hospital: R2 000
  • Endoscopic: Gastroscopy*, Colonoscopy* and Sigmoidoscopy: R1 500
  • Hysterectomy: R1 500
  • Joint replacement: R4 500
  • Laparoscopy, Hysteroscopy, Endometrial Ablation: R 2 000
  • Non-surgical medical admissions: R1 000
  • Reflux Surgery: R2 000
  • Spinal surgery: R4 500
    • *Diagnostic Gastroscopy / Colonoscopy performed in a provider’s consulting room will NOT be subject to a co-payment.
    • The highest co-payment will apply where more than one payment is required.
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
Homebirths must be assisted by a registered midwife, 10x pre-natal + 3x Post Natal Midwife visits.

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.

  • Adult test: HIV-Elisa
  • Child test (younger than 18 months): HIV-DNA-PCR and p24-antigen
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:

  • Gastroscopies
  • Colonoscopies
  • Plantar Wart removal
  • Removal of ingrown toenail
  • Varicose Vein injections/drainage
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:

  • Consultation
  • Fillings
  • Root Canal
  • Conscious sedation in dental rooms
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:

  1. Cystic Fibrosis
  2. Endometriosis
  3. GORD/GERD
  4. Osteoarthritis
  5. Osteoporosis
  6. Prostatic Hypertrophy Benign
  7. Psoriasis
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:

  • Sunglasses or lens tint > 35%
  • Repairs
  • Contact lens solution
  • Coloured contact lenses
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:

  • Blood pressure
  • Glucose
  • Cholesterol
  • Hb (Anemia)
  • Urine
  • Weight Loss/BMI counselling

Covers 1 test per beneficiary every two years for:

  • Pap Smear
  • Mammogram (only for women over 45 yrs)

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:

  • Crowns – 3 crowns or bridge units per family per annum
  • Plastic Dentures – 1 per jaw in a 2-year period per beneficiary
  • Metal Frame Dentures – 1 per jaw in a 5-year period per beneficiary
  • Orthodontics (refer schedule of exclusions)
  • Implants – 2 implants in a 5-year period per beneficiary (Implant omponent costs limited to a maximum R3,850 per implant)
  • Dental / Oral Surgery (refer schedule of exclusions)
  • Professional fees charged by a dental practitioner out-of-hospital subject to Benefit Booster™

Uniform application of Specialised Dentistry benefits applied to:

  • Dental Lab costs
  • Orthodontic benefits (i.e. 20% deposit, payment period and deduction of previous orthodontic phase costs).

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:

  • Blood pressure
  • Glucose
  • Cholesterol
  • Hb (Anemia)
  • Urine
  • Weight Loss/BMI counselling

Covers 1 test per beneficiary every two years for:

  • Pap Smear
  • Mammogram (only for women over 45 yrs)

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.