2012
Designed for the healthier member, but is also thoroughly reliable are included as well, ensuring you complete peace of mind for all your hospital expenses.
SPECTRA CAPRI CONTRIBUTIONS - 2012
|
BENEFICIARY TYPE |
INCOME CATEGORY (monthly) R0+ |
Total contribution |
Annual My Saver™ allowance |
|
Principal Member |
1,002 |
1,179 |
2,124 |
|
Insured contribution |
|||
|
My Saver™ contribution |
177 |
||
|
Adult Dependant |
798 |
939 |
1,692 |
|
Insured contribution |
|||
|
My Saver™ contribution |
141 |
||
|
Child Dependant |
|
536 |
960 |
|
Insured contribution |
456 |
||
|
My Saver™ contribution |
80 |
(all children will be charged for)
| BENEFIT DESCRIPTION |
BENEFIT |
NOTES |
|
Overall Annual Limit (OAL) |
Unlimited |
|
|
Dental / Oral Surgery Related General Anaesthesia and Intravenous Sedation
|
100% of SPECTRA Tariff Unlimited
|
Pre-authorisation required. 20% penalty (min R3,000) if not pre-authorised. Certain exclusions apply (refer schedule of exclusions)
Professional fees charged by a dental practitioner in-hospital subject to My Saver™ |
|
General hospitalisation |
100% of SPECTRA Tariff Unlimited |
Pre-authorisation required at least 48 hours prior to admission (non-emergency only). In case of emergency, authorisation required within 48 hours after admission. 20% Penalty (min. R3,000) if not pre-authorised Certain procedures are subject to the following co-payments: Arthroscopy R1,000 Dental in hospital R2,500 Endoscopic: Gastroscopy *, Colonoscopy * and Sigmoidoscopy R1,500 Hysterectomy R2,500 Joint replacement No benefit Laparoscopy, Hysteroscopy, Endometrial Ablation R2,500 Non-surgical medical admissions R1,000 Reflux Surgery R3,000 Spinal surgery No benefit (refer schedule of hospital co-payments)
Where services for a PMB in hospital are voluntarily obtained from a non-DSP, a co-payment or levy of 30% will apply
|
| Internal prostheses |
100% of SPECTRA Tariff at DSP only Limit = R90,000 per family (Sub-limits apply for certain procedures)
No benefit for joint replacement and spinal surgery 100% of Cost for PMBs |
Subject to pre-authorisation and clinical motivation Subject to “Fit for Surgery” certification |
|
Maternity |
100% of Cost at DSP only Unlimited |
Pre-authorisation required Home births subject to R11,000 per confinement Must be registered on Maternity Programme Antenatal classes subject to R500 per family If not authorised, a R10,000 limit will apply to Caesarean Sections |
|
Organ transplants, anti-rejection medication |
100% of SPECTRA Tariff Sub-limit = R350,000 per family |
Pre-authorisation required |
|
Pathology |
100% of SPECTRA Tariff M+0 = R1,500 M+1 = R2,200 M+2 = R2,600 M+3 = R3,200 M+4+ = R3,900 |
|
| Physiotherapy |
100% of SPECTRA Tariff Sub-limit = R3,500 per family
|
Pre-authorisation required |
|
Psychiatric treatment, substance & alcohol abuse & associated conditions |
100% of SPECTRA Tariff Sub-limit = R16,000 per family |
Pre-authorisation required |
|
Radiology |
100% of SPECTRA Tariff M+0 = R1,500 M+1 = R2,200 M+2 = R2,600 M+3 = R3,200 M+4+ = R3,900 |
Excludes: Specialised Radiology (refer Specialised Radiology benefit) |
|
Take-home medicine |
100% of SPECTRA Tariff 3 days post-hospitalisation |
|
| PMB | ||
| Prescribed Minimum Benefits | 100% of Cost | Limited to statutory algorithms and protocols for treatment received from a Designated Service Provider (DSP) |
| HIV BENEFIT | ||
| HIV/AIDS & related illnesses |
100% of Cost at DSP only Unlimited |
Must be enrolled on Scheme HIV/AIDS DSP and Management Programme Includes: HIV+ members, PEP (Post Exposure Prophylaxis) and MTC (Mother To Child transmission) Where any treatment is voluntarily obtained from a non-DSP, a 30% co-payment will apply. |
|
In-hospital
Out-of-Hospital
Prescribed medication
Pathology
Other out-of-hospital expenses
Non-HIV+ members
Pathology (VCT) |
100% of Cost at DSP Unlimited
100% of Cost at DSP Unlimited
100% of Cost at DSP Protocols apply
100% of Cost at DSP Protocols apply
2 per beneficiary per annum Diagnostic tests only |
Must be enrolled on Scheme HIV/AIDS DSP and Programme Pre-authorisation required Where any treatment is voluntarily obtained from a non-DSP, a 30% co-payment will apply.
Baseline monitoring tests as per protocols only
More than 2 tests per annum: subject to motivation and DSP Adults: HIV-Elisa Children < 18 months: HIV-DNA-PCR and p24-antigen |
| ADDITIONAL BENEFITS | ||
| Ambulance services |
100% of SPECTRA Tariff Unlimited |
No benefit unless obtained from Scheme-preferred provider and certified as essential by Medical Practitioner |
| Blood transfusions |
100% of SPECTRA Tariff Unlimited |
Pre-authorisation required |
| Dialysis |
100% of SPECTRA Tariff Sub-limit = R2,200 per treatment |
Pre-authorisation required |
| Investigative & surgical procedures in consulting rooms |
150% of SPECTRA Tariff Unlimited |
Including, but not limited to: Gastroscopies; Colonoscopies; Plantar Wart removal; Removal of ingrown toenail; Varicose Vein injections/ drainage Pre-authorisation required |
|
Oncology treatment Chemotherapy, Radiotherapy
Biological entities |
100% of SPECTRA Tariff Sub-limit = R250,000 per family
Subject to DSP only
Sub-limit = R150,000 per family |
Pre-authorisation required Limited to 1 x PET scan per annum for “staging” and subject to annual Specialised Radiology benefit Medication available from DSP only. 30% co-payment for use of non-DSP.
25% levy applicable |
|
Specialised Radiology (MRI / CT / PET / Bone Density & Radio-isotope scans) |
100% of SPECTRA Tariff Sub-limit = R8,000 per family |
Pre-authorisation required MRI and CT Scans: R1,500 co-payment per beneficiary per annum |
OUT-OF-HOSPITAL: MY SAVER™
|
MY SAVER™ (see contribution table below for annualised My Saver™ allowance) |
||
|
Acute Medication |
100% of SPECTRA Tariff Subject to My Saver™ |
|
|
Allied Health Services |
No benefit |
|
|
Conservative Dentistry / Oral Surgery |
100% of SPECTRA Tariff Subject to My Saver™ |
Including, but not limited to: Consultation; Fillings; Root Canal; Laughing gas in dental rooms / Surgical removal of impacted teeth |
|
Extended Chronic Medication (CDL+) |
No benefit |
|
|
External prostheses & appliances |
Subject to PMBs at DSP only |
Subject to pre-authorisation and clinical motivation |
|
General Practitioner Consultations and associated costs |
100% of SPECTRA Tariff Subject to My Saver™ |
|
|
Medical Specialists |
100% of SPECTRA Tariff Subject to My Saver™ |
Consultations and procedures |
|
Nursing services & Hospice |
No benefit |
|
|
Optical |
No benefit |
|
|
Pathology |
100% of SPECTRA Tariff Subject to My Saver™ |
|
|
Pharmacy-Advised Therapy (PAT) |
100% of SPECTRA Tariff Subject to My Saver™ |
|
|
Physiotherapy |
No benefit |
|
|
Psychiatric treatment, substance & alcohol abuse & associated conditions |
No benefit |
|
|
Radiology |
100% of SPECTRA Tariff Subject to My Saver™ |
Excludes: Specialised Radiology (refer Specialised Radiology benefit) |
|
Screening benefit |
100% of SPECTRA Tariff Subject to My Saver™ Subject to preferred provider only |
Covers 1 test per beneficiary per annum for each of the following: • Blood pressure • Glucose • Cholesterol • Hb (Anaemia) • Urine • PAP smear |
|
Specialised Dentistry |
No benefit |
|
SPECTRA Tariff:
1. The Reference Price List for healthcare services as adopted by the Board of Trustees from time to time;
2. Tariff as negotiated by SPECTRAMED; or
3. Single Exit Price for medicines plus the relevant dispensing fees according to a Scheme Formulary; or
4. Tariff as paid by SPECTRAMED for investigative and surgical procedures rendered in a provider’s consulting rooms; or
5. Tariff charged by a SPECTRAMED DSP or preferred provider.
Cost:
In relation to a benefit, the cost of providing for Prescribed Minimum Benefits that must be paid by the Scheme.
My Saver™
1. Personal Medical Savings Account as defined under Regulation 10 of the Medical Schemes Act 131 of 1998;
2. My Saver™ savings balance used to fund a defined list of day-to-day healthcare expenses;
3. On 1 January of each year, a member has access to the full annual savings allocation, even though contributions are paid monthly;
4. A member who terminates membership before year-end and who has spent an amount from My Saver™ that is more than the monthly contribution will be liable to refund the Scheme the overspent arrears amount;
5. Claims paid from My Saver™ are paid according to the Rules of the Scheme and subject to funds available in My Saver™;
6. Unused My Saver™ savings balances can be carried forward from one year to the next;
7. Unused My Saver™ savings balances are paid out to the member five months after termination of membership.
Pre-authorisation
Benefits in respect of the following categories are only available once pre-authorisation / registration has been obtained.
| CATEGORY | PROVIDER | PRE-AUTHORISATION | CONTACT NUMBER | CONTACT EMAIL |
| Emergency Transport & Ambulance | EUROP ASSISTANCE | Yes | 0800 773 2872 | Not applicable |
| Chronic benefit registration | MEDISCOR Chroniline™ | Yes | 0861 000 319 | spectramed@medisco |
| CDL medication delivery (all options) | OPTIPHARM | Yes | 0860 906 090 | chronic@spectramed.co.za |
| Dental authorisations (Specialised dentistry only) | SPECTRAMED | Yes | 0861 497 497 | dental@spectramed.co.za |
| Hospitalisation (including dentistry) | MSO | Yes | 0860 102 474 | preauth@mso.co.za |
| HIV/AIDS programme (registration/enquiries) | OPTIPHARM | Yes | 0860 906 090 | spectramed@optipharm.co.za |
| Oncology (Chemotherapy/ Radiotherapy) | MSO | Yes | 0860 102 474 | preauth@mso.co.za |
| Oncology medication (all options) | MSO | Yes | 0860 102 474 | preauth@mso.co.za |
