Spectra Cobalt Option

Spectra Cobalt is the number one choice for all members, as it offers the most generous benefits of all the Spectramed options. It is designed to cater for members who seek comprehensive coverage regarding healthcare, hospital and all general medical expenses.

Who should choose this option?

  • Mature members and settled families
  • People with substantial healthcare needs
  • Members who require more comprehensive healthcare cover with an unlimited hospital plan, a generous day-to-day savings account (My Saver™), and cover for 29 chronic conditions plus 14 CDL+ conditions
  • People who seek additional benefits such as the Benefit Booster™ (External Prostheses & Appliances; Optical; Psychiatric treatment, substance & alcohol abuse and associated conditions; Screening benefit; MediBooster; and Specialised Dentistry), which does not affect their My Saver™
  • Those in search of extensive preventative care
Contributions
Principal Member Adult Dependant Child Dependant
Risk Amount R4 628 R4 259 R1 622
Savings Amount R1 305 R1 201 R457
Total Monthly Contribution R5 933 R5 460 R2 079
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™
  • 100% Scheme tariff
  • Unlimited
General Hospitalisaion In-Hospital co-payments:
Arthroscopy: R1 500
Dental in hospital: R1 500
Endoscopic: Gastroscopy*, Colonoscopy* and Sigmoidoscopy: R1 500
Joint replacement: R1 000
Non-surgical medical admissions: R1 000
Reflux Surgery: R1 000
Spinal surgery: R1 000

  1. *Diagnostic Gastroscopy / Colonoscopy performed in a provider’s consulting room will NOT be subject to a co-payment.
  2. The highest co-payment will apply where more than one payment is required.
Internal Prostheses Subject to pre-authorisation and clinical motivation.
Subject to “Fit for Surgery” certification.

  • Limit: 3 spinal levels per beneficiary per annum.
    Sub-limits: Spinal: R50 000 (3 levels)
  • Limit: 1 joint replacement per beneficiary per annum.
    Sub-limits: Knee and Hip replacement: R50 000 (includes cement)
  • Limit: Other prostheses limited to R100 000 per surgical procedure.
Maternity Unlimited In-Hospital at DSP only.
Home births subject to R13 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, 10 pre-natal + 3 Post Natal Midwife visits.
Some of these benefits form part of your preventative care benefits.
Organ Transplants & Anti-rejection Medication Registration for organ transplants and anti-rejection medication must be done through the third-party service provider.
100% Scheme Tariff at DSP only.
Pathology 100% of Spectra Tariff
Physiotherapy Sub-limit = R11 600 per family
Psychiatric Treatment, Substance & Alcohol Abuse & Associated Conditions Sub-limit = R30 700 per family
100% of Spectra Tariff
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 2 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 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
Chemotherapy, Radiotherapy Sub-limit = R13 600 per family. 100% of Spectra Tariff.
Limited to 1x PET scan per annum for “staging” and subject to annual Specialised Radiology benefit
Biological & Targeted Therapy Entities Sub-limit = R260 000 per family.
20% 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 2nd scan per annum.
Sub-limit = R22 300 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 Sub-limit = R60 000 per family.
25% levy applicable.
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
  • Laughing gas in dental rooms
  • Surgical removal of impacted teeth
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. ADHD (in children)
  2. Alzheimer’s Disease
  3. Ankylosing Spondylitis
  4. Cystic Fibrosis
  5. Endometriosis
  6. GORD/GERD
  7. Gout
  8. Obsessive Compulsive Disorder
  9. Osteoarthritis
  10. Osteoporosis
  11. Paget’s Disease
  12. Psoriasis
  13. Wilson’s Disease
  14. Prostatic Hypertrophy Benign
General Practitioner (GP) Consultations & associated costs 100% Spectra tariff
Medical Specialists 100% Spectra tariff – Consultations & Procedures
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 = R9 300; M+1 = R11 300; M+2 = R12 800; M+3 = R15 600; M+4+ = R17 500
External Prostheses & Appliances Subject to pre-authorisation and clinical motivation and registration with the preferred provider
Optical Optical Sub-limit = R3 200 per beneficiary.
Frame sub-limit = R1 200 per beneficiary (included in optical sub-limit).
Benefit available every year from date of treatment for frames and lenses (per beneficiary).Specific exclusions:

  • Sunglasses or lens tint > 35%
  • Repairs
  • Contact lens solution
  • Coloured contact lenses
Psychiatric treatment, substance & alcohol abuse and associated conditions Sub-limit = R6 600 per family
Preventative & Screening Benefit 100% of Spectra Tariff.
Sub-limit = R2 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 800 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 = R7 150; M+1 = R8 950; M+2 = R10 700; M+3 = R12 550; M+4 = R14 300

Including, but not limited to:

  • 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 component 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).
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 = R2 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 2x consultations per beneficiary per year.
Subject to preferred provider only.
Subject to Benefit Booster™ limit
Well Baby Consultations 1 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 800 per family.
Subject to registration and Self-Health Assessment.
Only available through Preferred Provider.
Subject to Benefit Booster™ limit.