CAMAF Benefit Brochure 2018

CAMAF BENEFIT OPTION 2018 – PDF DOWNLOAD

CAMAF Beneft Options: Quick Summary
 VitalEssential PlusNetwork ChoiceFirst ChoiceDouble PlusAlliance
Hospital Facility FeesAny private hospitalAny private hospitalAny private hospitalAny private hospitalAny private hospitalAny private hospital.
Private wards
Attending Doctor's and
Specialists in Hospital
Up to 300% CBTUp to 200% CBTUp to 100% CBTUp to 100% CBTUp to 300% CBTUp to 300% CBT
Chronic condition
cover: medicines and
consults
63 Conditions27 Conditions27 Conditions27 Conditions63 Conditions64 Conditions
Radiology and
Pathology
Unlimited In or Out of
Hospital
Unlimited In Hospital.
Out of Hospital from MSA
Limits apply In and Out
of hospital
Limits apply In and Out
of hospital
Unlimited In or Out
of Hospital
Unlimited In or Out of
Hospital
Preventative Wellness
Benefits
14 extra benefits4 extra benefits10 extra benefits10 extra benefits14 extra benefits14 extra benefits
Day to Day Overall
Limit (Principal
Member)
--R3 040 for Medicines.
R9 360 for Specialists.
R3 040 for Other.
From DSP only
R3 040 for Medicines.
R9 360 for Specialists.
R3 040 for Other
Paid at 80%
R 11 800R 30 200
Medical Savings
Account (Principal
Member)
-R 6 000--R 4 260R 6 540
Benefit Option: Vital
Any Private Hospital: No limits
Attending Doctors and Specialists: Up to 300% of CBT
63 Chronic Conditions: Medication and consultations. Covers the medication and necessary consultations and procedures. Includes unlimited appropriate biological drugs and specialised technology as well as door to door medication delivery
Unlimited X-Rays and Blood Tests IN and OUT of hospital including MRI’s and CT’s
Screening Benefits
3 Month post hospitalisation benefit
External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor
Check-Ups and Vaccines: GP, Specialist, Dental, Optometry, ECG
VitalLogo

VITAL

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

In Hospital and Prescribed Minimum Benefit 

Hospital Accommodation
Including Confinements, Subject to Pre-Authorisation

100% of Negotiated Rate in general ward and specialised units

Attending Doctors and Specialists
Consultations

Medical and Surgical Procedures including Confinements
Subject to Pre-Authorisation

Up to 300% CBT


100% of Scheme Rate

Supplementary Healthcare In Hospital
(Eg. Physiotherapy and Psychotherapy)

100% CBT

Blood Transfusions
(In and Out of Hospital)

100% of cost

Radiology In Hospital
Advanced Scans (Mri/Ct/Pet)
Subject to Pre-Authorisation

100% CBT
100% CBT

Pathology
In Hospital

100% Negotiated Rate

Internal Prosthesis
Subject to Pre-Authorisation

100% of cost

Home Nursing
Up to 21 Days, Subject to Pre-Authorisation

100% CBT

Step Down Approved Facilities (Only, up to 90 Days)
Subject to Pre-Authorisation

100% Negotiated Rate

Medication
In Hospital

100% SEP plus dispensing fee

TTO Medication
Up to One Week’s Supply

100% SEP plus dispensing fee

Substance Abuse

PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year,
subject to pre-authorisation and limited to 21 days

Chronic PMB CDL Medication And Treatment - Subject
to Pre-Authorisation and Protocols
Refer to Chronic Disease List

100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

PMB DTP Treatment
Out of Hospital Treatment Subject to Registration of
Condition and Pre-Authorisation

Medication - 100% SEP plus dispensing fee, subject to MMAP and DSP. Consultations and procedures
- at cost

Oncology
Subject to Pre-Authorisation and Icon Protocols#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures- at 100% Scheme Rate. The ICON Core benefits apply

#Please refer to website for ICON benefit structures

VitalLogo

VITAL

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Preventative Wellness Cover 

Camaf Lifestyle Programme
per Adult Beneficiary

INCLUDES: • Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy • Access to e|Care
portal with online wellness solutions to monitor your health and promote balanced, healthy living
• Comprehensive wellness report plus personalised health articles in weekly emails when you complete your wellness assessment online.

One Gp Consultation Only
ICD 10 Code Specific to General Check Up Only

100% CBT per beneficiary

One Specialist Consultation
ICD 10 Code Specific to General Check Up Only. Gynaecologists,
Urologists, or Specialist Physicians**
For Beneficiaries over 16 years. Paediatricians for
Beneficiaries under 16 Years

100% CBTper beneficiary

Psychotherapy

100% CBT limited to R10 840 per beneficiary

One Dietician Consultation

100% CBT per beneficiary

One Dentistry Consultation
General Check Up Only - excludes consumables

100% CBT per beneficiary

ONE ECG
(Performed by Gp or Specialist Physician**)
ICD 10 Code Specific to General Check Up Only
- excludes consumables

100% CBT per adult beneficiary

One Optometrist Consultation

Within the PPN Network: 100% of cost for a composite consultation inclusive of the refraction, a glaucoma screening, and visual field screening. Outside of the PPN Network: 100% Optical Assistant Rates

Metabolic Screening for New Born Babies

100% Negotiated Rate per new born baby

Immunisation and Vaccines
(Cost of Immunisation and Vaccine Only

SEP plus a dispensing fee, limited to R1 590 per beneficiary

Cervical Cancer Vaccine
(Cost of Vaccine Only)

Females between 9 and 16 years of age
(SEP plus dispensing fee)

One Hiv Vct Test

100% cost per beneficiary

Melanoma Screening Test

100% CBT per adult beneficiary

Umbilical Stem Cell Harvesting

Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits.

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

VitalLogo

VITAL

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Not Subject to the Annual Overall Benefit Limit 

Basic and Advanced Radiology
Out of Hospital
Must be performed by a registered Radiologist, on referral
from medical practitioner only. Advanced scans (mri/ct/pet)
subject to pre-authorisation

100% CBT

Pathology
Out of Hospital
Performed by a registered Pathologist and referred by a
Medical Practitioner
Pre-Authorisation required for Advanced Pathology

100% Negotiated Rate or CBT

Post-Hospitalisation
Consultations and Treatment up to 90 days

300% CBT for attending practitioners
100% CBT for auxiliary services

Medication For Additional Chronic Conditions
(Subject to pre-authorisation) refer to
Additional Chronic Conditions List

100% SEP plus a dispensing fee, subject to RP and DSP
Consultations 100% CBT

External Appliances (subject to referral)
In and out of hospital - purchase, hire and maintenance
Hearing aids - 1 claim per 3 year
Cycle for over 16 years of age, younger than 16 years of age -
18 month cycle
Wheelchairs - 3 year cycle
Insulin pumps, subject to
Pre-authorisation and DSP - 4 year cycle
Breast Pumps and Apnoea Monitors - three months prior to
expected due date and within six months after the birth of the
baby. Subject to registration on the Mother to be Programme

100% of cost subject to the overall limit of R 36 700 per beneficiary and subject to the following sub-limits:
Hearing Aids: R31 800
Wheelchairs for Quadriplegics: R31 800
Standard Wheelchairs: R22 400
Insulin Pumps: R36 700
Other external appliances: R 8 000
• Baby Apnoea monitors: R 2 500
• Breast pumps: R 4 100

International Travel Cover

R10 million per beneficiary per journey for emergency medical costs while you travel outside South
Africa. This cover is for a period of 90 days from your departure from South Africa. Cover for
pre-existing conditions is limited to R150,000 unless additional cover is arranged.

Netcare 911 Emergency Services

Unlimited - Subject to Netcare 911 authorisation

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

Monthly Contribution Rates: Vital

Income Category - per month Total Monthly Contribution
R0 - R40 000Adult
Child
R1 935
R 990
R40 001 - R100 000Adult
Child
R2 150
R1 100
R100 001+Adult
Child
R2 365
R1 210
Benefit Option: Essential Plus
Any Private Hospital: No limits
Attending Doctors and Specialists: Up to 200% of CBT
27 Chronic Conditions: Medication and consultations
Unlimited X-Rays and Blood Tests IN hospital including MRI and CT scans
Screening Benefits
Psychotherapy and Immunisation Benefits
EssentialPlusLogo

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

In Hospital and Prescribed Minimum Benefit

Hospital Accommodation
Including Confinements, Subject to Pre-Authorisation

100% of Negotiated Rate in general ward and specialised units

Attending Doctors and Specialists
Consultations

Medical and Surgical Procedures including Confinements
Subject to Pre-Authorisation

Up to 200% CBT
100% of Scheme Rate

Supplementary Healthcare In Hospital
(Eg. Physiotherapy and Psychotherapy)

100% CBT

Blood Transfusions
(In and Out of Hospital)

100% of cost

Radiology In Hospital
Advanced Scans (Mri/Ct/Pet)
Subject to Pre-Authorisation

100% CBT
100% CBT

Pathology
In Hospital

100% Negotiated Rate

Internal Prosthesis
Subject to Pre-Authorisation

100% of cost

Home Nursing
Up to 21 Days, Subject to Pre-Authorisation

100% CBT

Step Down Approved Facilities (Only, up to 90 Days)
Subject to Pre-Authorisation

100% Negotiated Rate

Medication
In Hospital

100% SEP plus dispensing fee

TTO Medication
Up to One Week’s Supply

100% SEP plus dispensing fee

Substance Abuse

PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year,
subject to pre-authorisation and limited to 21 days

Chronic PMB CDL Medication And Treatment - Subject
to Pre-Authorisation and Protocols
Refer to Chronic Disease List

100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

PMB DTP Treatment
Out of Hospital Treatment Subject to Registration of
Condition and Pre-Authorisation

Medication - 100% SEP plus dispensing fee, subject to MMAP and DSP. Consultations and procedures
- at cost

Oncology
Subject to Pre-Authorisation and Icon Protocols#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures at 100% DSP Tarrif. The DSP is the ICON network. The ICON Essential benefits apply

#Please refer to website for ICON benefit structures

EssentialPlusLogo

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Preventative Wellness Cover 

Camaf Lifestyle Programme
per Adult Beneficiary

INCLUDES: • Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy
• Access to e|Care portal with online wellness solutions to monitor your health and promote balanced, healthy living
• Comprehensive wellness report plus personalised health articles in weekly emails when you complete your wellness assessment online.

One Gp Consultation Only
ICD 10 Code Specific to General Check Up Only

Subject to Medical Savings Account

One Specialist Consultation
ICD 10 Code Specific to General Check Up Only. Gynaecologists,
Urologists, or Specialist Physicians**
For Beneficiaries over 16 years. Paediatricians for
Beneficiaries under 16 Years

Subject to Medical Savings Account

Psychotherapy

100% CBT limited to R10 840 per beneficiary

One Dietician Consultation

Subject to Medical Savings Account

One Dentistry Consultation
General Check Up Only - excludes consumables

Subject to Medical Savings Account

ONE ECG
(Performed by Gp or Specialist Physician**)
ICD 10 Code Specific to General Check Up Only
- excludes consumables

Subject to Medical Savings Account

One Optometrist Consultation

Subject to Medical Savings Account

Metabolic Screening for New Born Babies

Subject to Medical Savings Account

Immunisation and Vaccines
(Cost of Immunisation and Vaccine Only

SEP plus a dispensing fee, limited to R1 590 per beneficiary

Cervical Cancer Vaccine
(Cost of Vaccine Only)

Females between 9 and 16 years of age
(SEP plus dispensing fee)

One Hiv Vct Test

100% CBT per beneficiary

Melanoma Screening Test

Subject to Medical Savings Account

Umbilical Stem Cell Harvesting

Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits.

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

EssentialPlusLogo

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Not Subject to the Annual Overall Benefit Limit 

Basic and Advanced Radiology
Out of Hospital
Must be performed by a registered Radiologist, on referral
from medical practitioner only. Advanced scans (mri/ct/pet)
subject to pre-authorisation

Subject to Medical Savings Account

Pathology
Out of Hospital
Performed by a registered Pathologist and referred by a
Medical Practitioner
Pre-Authorisation required for Advanced Pathology

Subject to Medical Savings Account

Post-Hospitalisation
Consultations and Treatment up to 90 days

Subject to Medical Savings Account

Medication For Additional Chronic Conditions
(Subject to pre-authorisation) refer to
Additional Chronic Conditions List

Depression only. 100% SEP plus a dispensing fee, subject to RP and DSP
Consultations 100% CBT

External Appliances (subject to referral)
In and out of hospital - purchase, hire and maintenance
Hearing aids - 1 claim per 3 year
Cycle for over 16 years of age, younger than 16 years of age -
18 month cycle
Wheelchairs - 3 year cycle
Insulin pumps, subject to
Pre-authorisation and DSP - 4 year cycle
Breast Pumps and Apnoea Monitors - three months prior to
expected due date and within six months after the birth of the
baby. Subject to registration on the Mother to be Programme

Subject to Medical Savings Account

International Travel Cover

R10 million per beneficiary per journey for emergency medical costs while you travel outside South
Africa. This cover is for a period of 90 days from your departure from South Africa. Cover for
pre-existing conditions is limited to R150,000 unless additional cover is arranged.

Netcare 911 Emergency Services

Unlimited - Subject to Netcare 911 authorisation

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

EssentialPlusLogo

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Subject to the Annual Overall Day-To-Day Benefit Limit 

Day to Day Benefits
Benefits Below are Subject to the Overall Annual Limit

Limited to funds available in the beneficiary’s Medical Savings Account

Gp’s and Dentists
Dental X-Rays Performed by Dentists,
Consultations And Procedures Performed by these
Practitioners; Basic Dentistry

Subject to Medical Savings Account

Specialists
Consultations, Procedures and Radiology Performed by these
Practitioners

Subject to Medical Savings Account

Acute Medication
Including Injections and Materials

Subject to Medical Savings Account

Casualty and Out Patient Treatment at a Hospital
All Medications will be paid out of Acute Medication Benefit

Subject to Medical Savings Account

Nurse Visits

Subject to Medical Savings Account

Supplementary Health
Audiology, Chiropractors, Dieticians, Homoeopaths,
Occupational Therapy, Physiotherapists, Biokineticists,
Podiatry and Speech Therapy

Subject to Medical Savings Account

Advanced Dentistry
Crowns, Bridges, Orthodontics, Dentures

Subject to Medical Savings Account

Over the Counter Medication

Subject to Medical Savings Account

Laser K
No Approval for Surgery where Spectacles obtained in
previous 12 months
If the Laser K Benefit is utilised, No Spectacle and Contact
Lense Benefit allowed for 2 years

Subject to Medical Savings Account

Ante-Natal Foetal Scans
per Pregnancy

Subject to Medical Savings Account

Ante-Natal Classes

Subject to Medical Savings Account

Spectacles and Lenses
from Optometrist Only Annual Benefit, unless otherwise stated

Subject to Medical Savings Account

Monthly Contribution Rates: Essential Plus

Income Category - per month Total Monthly Contribution
R0 - R100 000Principal
Adult
Child
R1 580
R1 250
R 735
Monthly Msa ContributionPrincipal
Adult
Child
R 500
R 499
R 235
Total Monthly ContributionPrincipal
Adult
Child
R2 080
R1 650
R 970
R100 001+Principal
Adult
Child
R1 892
R1 498
R 881
Monthly Msa ContributionPrincipal
Adult
Child
R 500
R 400
R 235
Total Monthly ContributionPrincipal
Adult
Child
R2 392
R1 898
R1 116
Benefit Option: Network Choice
Network Hospital: No limits (DSP hospital group is Netcare)
Attending Doctors: Up to 100% CBT only at DSP
27 Chronic Conditions: medication and consultations. Includes unlimited appropriate biological drugs and
specialised technology and door to door medication delivery
X-Rays and Blood Tests Advanced scans limited to R32 800 per family
Screening Benefits
Vaccines

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

In Hospital and Prescribed Minimum Benefits 

Hospital Accommodation
Including Confinements, Subject to Pre-Authorisation

100% of DSP Tariff as per protocols. The DSP hospital group is Netcare.

Attending Doctors and Specialists
Consultations

Medical and Surgical Procedures including Confinements
Subject to Pre-Authorisation

Up to 100% CBT
100% of CBT

Supplementary Healthcare In Hospital
(Eg. Physiotherapy and Psychotherapy)

100% CBT

Blood Transfusions
(In and Out of Hospital)

100% of cost

Radiology In Hospital
Advanced Scans (Mri/Ct/Pet)
Subject to Pre-Authorisation

100% CBT
100% limited to R35 100 per family

Pathology
In Hospital

100% CBT

Internal Prosthesis
Subject to Pre-Authorisation

100% of cost limited to R35 100 per family

Home Nursing
Up to 21 Days, Subject to Pre-Authorisation

100% CBT (in lieu of hospitalisation only)

Step Down Approved Facilities (Only, up to 90 Days)
Subject to Pre-Authorisation

100% DSP Tariff

Medication
In Hospital

100% SEP plus dispensing fee

TTO Medication
Up to One Week’s Supply

100% SEP plus dispensing fee

Substance Abuse

PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year,
subject to pre-authorisation and limited to 21 days

Chronic PMB CDL Medication And Treatment - Subject
to Pre-Authorisation and Protocols
Refer to Chronic Disease List

100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

PMB DTP Treatment
Out of Hospital Treatment Subject to Registration of
Condition and Pre-Authorisation

Medication - 100% SEP plus dispensing fee, subject to MMAP and DSP. Consultations and procedures
- at cost

Oncology
Subject to Pre-Authorisation and Icon Protocols#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures
- at 100% DSP Tarrif. The DSP is the ICON network. The ICON Essential benefits apply

#Please refer to website for ICON benefit structures

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Preventative Wellness Cover 

Camaf Lifestyle Programme
per Adult Beneficiary

INCLUDES: • Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy • Access to e|Care
portal with online wellness solutions to monitor your health and promote balanced, healthy living
• Comprehensive wellness report plus personalised health articles in weekly emails when you complete
your wellness assessment online.

One Gp Consultation Only
ICD 10 Code Specific to General Check Up Only

100% CBT per beneficiary (Network Doctor only)

One Specialist Consultation
ICD 10 Code Specific to General Check Up Only. Gynaecologists,
Urologists, or Specialist Physicians**
For Beneficiaries over 16 years. Paediatricians for
Beneficiaries under 16 Years

100% CBT per beneficiary

Psychotherapy

100% CBT limited to R10 840 per beneficiary

One Dentistry Consultation
General Check Up Only - excludes consumables

100% CBT per beneficiary

ONE ECG
(Performed by Gp or Specialist Physician**)
ICD 10 Code Specific to General Check Up Only
- excludes consumables

100% CBT per adult beneficiary

One Optometrist Consultation

Refer to spectacle and lenses benefits

Metabolic Screening for New Born Babies

100% Negotiated Rate per new born baby

Immunisation and Vaccines
(Cost of Immunisation and Vaccine Only

SEP plus a dispensing fee, subject to MMAP, limited to R1 590 per beneficiary

Cervical Cancer Vaccine
(Cost of Vaccine Only)

Females between 9 and 16 years of age
(SEP plus dispensing fee)

One Hiv Vct Test

100% CBT per beneficiary

Umbilical Stem Cell Harvesting

Negotiated discount with Cryo-Save. Note:Please note that CAMAF does not cover expenses related
to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical
condition. The cash discount that is offered is passed directly on to you and is not paid from your
health plan benefits.

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Not Subject to the Annual Overall Benefit Limit 

Basic and Advanced Radiology
Out of Hospital
Must be performed by a registered Radiologist, on referral
from medical practitioner only. Advanced scans (mri/ct/pet)
subject to pre-authorisation

Basic Radiology: Referrals by DSP or specialist, 100% CBT limited to R4 100 per beneficiary Advanced scans: 100% CBTlimited to R35 100 per family (on referral by DSP or specialist)

Pathology
Out of Hospital
Performed by a registered Pathologist and referred by a
Medical Practitioner
Pre-Authorisation required for Advanced Pathology

Referred by DSP or specialist, 100% CBT, limited to R6 550 per beneficiary

Medication For Additional Chronic Conditions
(Subject to pre-authorisation) refer to
Additional Chronic Conditions List

Depression only. 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT

External Appliances (subject to referral)
In and out of hospital - purchase, hire and maintenance
Hearing aids - 1 claim per 3 year
Cycle for over 16 years of age, younger than 16 years of age -
18 month cycle
Wheelchairs - 3 year cycle
Insulin pumps, subject to
Pre-authorisation and DSP - 4 year cycle
Breast Pumps and Apnoea Monitors - three months prior to
expected due date and within six months after the birth of the
baby. Subject to registration on the Mother to be Programme

100% NAPPI price or 100% of cost, limited to R6 300 per beneficiary and subject to DSP or Specialist referral and subject to the following sub-limits: • Baby Apnoea monitors: R 2 100 • Breast pumps: R 3 600

International Travel Cover

R10 million per beneficiary per journey for emergency medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa. Cover for pre-existing conditions is limited to R150,000 unless additional cover is arranged.

Netcare 911 Emergency Services

Unlimited - Subject to Netcare 911 authorisation

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Subject to the Annual Overall Day-To-Day Benefit Limit 

Day to Day Benefits
Benefits Below are Subject to the Overall Annual Limit

Annual overall limit: Beneficiary specific limits:
(a) Medicines R 3 040
(b) Advanced Dentistry R 6 370
(c) Other R 3 040
(d) Specialists R 9 360

Gp’s and Dentists
Dental X-Rays Performed by Dentists,
Consultations And Procedures Performed by these
Practitioners; Basic Dentistry

100% negotiated rate
subject to sublimit (c) - Network GP only

Specialists
Consultations, Procedures and Radiology Performed by these
Practitioners

100% CBT
Subject to limit (d) (on referral from a network GP only)

Acute Medication
Including Injections and Materials

100% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a) (on referral from a network GP only)

Non-Dsp Visits
To Doctors' Rooms

One non-network visit per beneficiary or two per family, 20% co-payment

Casualty and Out Patient Treatment at a Hospital
All Medications will be paid out of Acute Medication Benefit

One casualty visit per family (facility fee, consumed meds and materials).
Limited to R 1 310
Associated claims such as radiology and pathology are not covered unless it is a PMB or DTP.

Nurse Visits

100% CBT subject to limit (c)

Supplementary Health
Audiology, Chiropractors, Dieticians, Homoeopaths,
Occupational Therapy, Physiotherapists, Biokineticists,
Podiatry and Speech Therapy

100% CBT limited to R2 550 per beneficiary on referral from DSP or from a Specialist.
Subject to limit (c)
BENEFIT SPECIFIC LIMITS

Advanced Dentistry
Crowns, Bridges, Orthodontics, Dentures

100% of CBT
Subject to limit (b) dental implants excluded

Over the Counter Medication

80% SEP plus a dispensing fee, subject to MMAP, limited to R1 560 per beneficiary. Subject to limit (a)

Ante-Natal Foetal Scans
per Pregnancy

3 scans at 80% CBT. Subject to limit (c)

Ante-Natal Classes

80% CBT subject to sub-limit R970 per pregnancy. Subject to limit (c)

Spectacles and Lenses
from Optometrist Only Annual Benefit, unless otherwise stated

The benefit PER BENEFICIARY at a PPN provider would be as follows:
For the benefit cycle of 24 months from date of claiming, each beneficiary is entitled to: One Composite Consultation inclusive
of a Refraction, Tonometry and Visual Field screening AND EITHER SPECTACLES - A PPN Frame to the value of R150 or R600
off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear Aquity Single Vision; Clear
Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R800.
The benefit PER BENEFICIARY at a NON PPN provider would be as follows:
One consultation per Beneficiary during the Benefit Cycle, limited to a maximum cost of R715 AND EITHER SPECTACLES - A
frame benefit of R600 towards the cost of a frame and/or lens enhancements and one pair of lenses: either one pair of clear
single vision spectacle lenses limited to R175 per lens or one pair of clear flat top bifocal spectacle lenses limited to R380 per
lens or one pair of clear flat top Multifocal lenses limited to R695 per lens OR CONTACT LENSES - Contact Lenses to the value
of R800.

Monthly Contribution Rates: Network Choice

Income Category - per month Total Monthly Contribution
R0 - R16 440Principal
Adult
1st Child
(rest are free)
R1 375
R1 150
R 598
R16 441 - R22 050Principal
Adult
1st Child
(rest are free)
R1 635
R1 305
R 735
R22 051 - R33 080Principal
Adult
Child
R1 956
R1 515
R 975
R33 081+Principal
Adult
Child
R2 600
R2 098
R1 277
Benefit Option: First Choice
Any Private Hospital: No limits
Attending Dr’s and Specialists: Up to 100%CBT
27 Chronic Conditions: medication and consultations. Includes unlimited appropriate biological drugs and
specialised technology and door to door medication delivery
X-Rays and Blood Tests Advanced scans limited to R32 800 per family
Screening Benefits
80% of GP, Specialists, Dental, Optometry, Check-ups, ECG, Vaccines

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

In Hospital and Prescribed Minimum Benefits 

Hospital Accommodation
Including Confinements, Subject to Pre-Authorisation

100% of Negotiated Rate in general ward and specialised units

Attending Doctors and Specialists
Consultations

Medical and Surgical Procedures including Confinements
Subject to Pre-Authorisation

Up to 100% CBT
100% of CBT
Exclusions: cochlear implants, excimer laser, osseo-integrated implants

Supplementary Healthcare In Hospital
(Eg. Physiotherapy and Psychotherapy)

100% CBT

Blood Transfusions
(In and Out of Hospital)

100% of cost

Radiology In Hospital
Advanced Scans (Mri/Ct/Pet)
Subject to Pre-Authorisation

100% CBT
100% CBT limited to R35 100 per family

Pathology
In Hospital

100% CBT

Internal Prosthesis
Subject to Pre-Authorisation

100% of cost limited to R35 100 per family

Home Nursing
Up to 21 Days, Subject to Pre-Authorisation

100% CBT (in lieu of hospitalisation only)

Step Down Approved Facilities (Only, up to 90 Days)
Subject to Pre-Authorisation

100% of Negotiated Rate

Medication
In Hospital

100% SEP plus dispensing fee

TTO Medication
Up to One Week’s Supply

100% SEP plus dispensing fee

Substance Abuse

PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year,
subject to pre-authorisation and limited to 21 days

Chronic PMB CDL Medication And Treatment - Subject
to Pre-Authorisation and Protocols
Refer to Chronic Disease List

100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

PMB DTP Treatment
Out of Hospital Treatment Subject to Registration of
Condition and Pre-Authorisation

Medication - 100% DSP plus dispensing fee, subject to MMAP and DSP. Consultations and procedures
- at cost

Oncology
Subject to Pre-Authorisation and Icon Protocols#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures
- at 100% DSP Tarrif. The DSP is the ICON network. The ICON Essential benefits apply

#Please refer to website for ICON benefit structures

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Preventative Wellness Cover 

Camaf Lifestyle Programme per Adult Beneficiary

INCLUDES: • Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy • Access to e|Care portal with online wellness solutions to monitor your health and promote balanced, healthy living
• Comprehensive wellness report plus personalised health articles in weekly emails when you complete your wellness assessment online.

One Gp Consultation Only ICD 10 Code Specific to General Check Up Only

100% CBT per beneficiary

One Specialist Consultation ICD 10 Code Specific to General Check Up Only. Gynaecologists, Urologists, or Specialist Physicians** For Beneficiaries over 16 years. Paediatricians for Beneficiaries under 16 Years

100% CBT per beneficiary

Psychotherapy

100% CBT limited to R10 840 per beneficiary

One Dentistry Consultation General Check Up Only - excludes consumables

100% CBT per beneficiary

ONE ECG (Performed by Gp or Specialist Physician**) ICD 10 Code Specific to General Check Up Only - excludes consumables

100% CBT per adult beneficiary

One Optometrist Consultation

Refer to spectacle and lenses benefits

Metabolic Screening for New Born Babies

100% Negotiated Rate per new born baby

Immunisation and Vaccines (Cost of Immunisation and Vaccine Only

SEP plus a dispensing fee, subject to MMAP, limited to R1 590 per beneficiary

Cervical Cancer Vaccine (Cost of Vaccine Only)

Females between 9 and 16 years of age
(SEP plus dispensing fee)

One Hiv Vct Test

100% CBT per beneficiary

Umbilical Stem Cell Harvesting

Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related
to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical
condition. The cash discount that is offered is passed directly on to you and is not paid from your
health plan benefits.

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Not Subject to the Annual Overall Benefit Limit 

Basic and Advanced Radiology
Out of Hospital
Must be performed by a registered Radiologist, on referral
from medical practitioner only. Advanced scans (mri/ct/pet)
subject to pre-authorisation

Basic Radiology: 100% CBT limited to R4 100 per beneficiary
Advanced scans: 100% CBT limited to R35 100 per family

Pathology
Out of Hospital
Performed by a registered Pathologist and referred by a
Medical Practitioner
Pre-Authorisation required for Advanced Pathology

100% CBT limited to R6 550 per beneficiary

Medication For Additional Chronic Conditions
(Subject to pre-authorisation) refer to
Additional Chronic Conditions List

Depression only. 100% SEP plus a dispensing fee, subject to RP and DSP
Consultations 100% CBT

External Appliances (subject to referral)
In and out of hospital - purchase, hire and maintenance
Hearing aids - 1 claim per 3 year
Cycle for over 16 years of age, younger than 16 years of age -
18 month cycle
Wheelchairs - 3 year cycle
Insulin pumps, subject to
Pre-authorisation and DSP - 4 year cycle
Breast Pumps and Apnoea Monitors - three months prior to
expected due date and within six months after the birth of the
baby. Subject to registration on the Mother to be Programme

100% NAPPI price or 100% of cost, in hospital and 80% of cost out of hospital with an overall limit of R6 300 per beneficiary and subject to the following sub-limits:
• Baby Apnoea monitors: R 2 100
• Breast pumps: R 3 600

International Travel Cover

R10 million per beneficiary per journey for emergency medical costs while you travel outside SouthAfrica. This cover is for a period of 90 days from your departure from South Africa. Cover for
pre-existing conditions is limited to R150,000 unless additional cover is arranged.

Netcare 911 Emergency Services

Unlimited - Subject to Netcare 911 authorisation

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Subject to the Annual Overall Day-To-Day Benefit Limit 

Day to Day Benefits
Benefits Below are Subject to the Overall Annual Limit

Annual overall limit: Beneficiary specific limits:
(a) Medicines R 3 040
(b) Advanced Dentistry R 6 370
(c) Other R 3 040
(d) Specialists R 9 360

Gp’s and Dentists
Dental X-Rays Performed by Dentists,
Consultations And Procedures Performed by these
Practitioners; Basic Dentistry

80% CBT
subject to sublimit (c)

Specialists
Consultations, Procedures and Radiology Performed by these
Practitioners

80% CBT
Subject to limit (d)

Acute Medication
Including Injections and Materials

80% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a)

Casualty and Out Patient Treatment at a Hospital
All Medications will be paid out of Acute Medication Benefit

Medication: 80% SEP plus a dispensing fee subject to limit (a)
Treatment: 80% CBT subject to limit (c)

Nurse Visits

80% CBT subject to limit (c)

Supplementary Health
Audiology, Chiropractors, Dieticians, Homoeopaths,
Occupational Therapy, Physiotherapists, Biokineticists,
Podiatry and Speech Therapy

80% CBT limited to R2 550
Subject to limit (c)
BENEFIT SPECIFIC LIMITS

Advanced Dentistry
Crowns, Bridges, Orthodontics, Dentures

50% of CBT
Subject to limit (b) dental implants excluded

Over the Counter Medication

80% SEP plus a dispensing fee, subject to MMAP, limited to R1 560 per beneficiary. Subject to limit (a)

Ante-Natal Foetal Scans
per Pregnancy

3 scans at 80% CBT. Subject to limit (c)

Ante-Natal Classes

80% CBT subject to sub-limit R970 per pregnancy. Subject to limit (c)

Spectacles and Lenses
from Optometrist Only Annual Benefit, unless otherwise stated

The benefit PER BENEFICIARY at a PPN provider would be as follows:
For the benefit cycle of 24 months from date of claiming, each beneficiary is entitled to: One Composite Consultation inclusive
of a Refraction, Tonometry and Visual Field screening AND EITHER SPECTACLES - A PPN Frame to the value of R150 or R600
off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear Aquity Single Vision; Clear
Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R800.
The benefit PER BENEFICIARY at a NON PPN provider would be as follows:
One consultation per Beneficiary during the Benefit Cycle, limited to a maximum cost of R715 AND EITHER SPECTACLES - A
frame benefit of R600 towards the cost of a frame and/or lens enhancements and one pair of lenses: either one pair of clear
single vision spectacle lenses limited to R175 per lens or one pair of clear flat top bifocal spectacle lenses limited to R380 per
lens or one pair of clear flat top Multifocal lenses limited to R695 per lens OR CONTACT LENSES - Contact Lenses to the value
of R800.

Monthly Contribution Rates: First Choice

Income Category - per month Total Monthly Contribution
R0 - R8 520Adult
Child
R 935
R 570
R8 521 - R16 440Adult
Child
R1 485
R 880
R16 441 - R22 050Adult
Child
R2 230
R 1 297
R22 051 - R33 080Adult
Child
R2 775
R1 825
R33 081+Adult
Child
R3 035
R1 980
Benefit Option: Double Plus
Any Private Hospital: No limits
Attending Dr’s and Specialists: Up to 300% CBT
63 Chronic Conditions Medication and Consultations. Includes unlimited appropriate Biological Drugs and
Specialised Technology
Unlimited X-rays and Blood Tests In and Out of Hospital including mri and ct Scans
Screening Benefits
3 Month Post Hospitalisation Benefit
External Appliances: wheelchair, hearing aid, breast pump, baby sleep monitor
Check-ups and Vaccines: Gp, Specialist, Dental, Optometry, Ecg
Infertility R55 700 per family
doublePluslogo

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

In Hospital and Prescribed Minimum Benefits 

Hospital Accommodation
Including Confinements, Subject to Pre-Authorisation

100% of Negotiated Rate in general ward and specialised units

Attending Doctors and Specialists
Consultations

Medical and Surgical Procedures including Confinements
Subject to Pre-Authorisation

Up to 300% CBT
100% of Scheme Rate

Supplementary Healthcare In Hospital
(Eg. Physiotherapy and Psychotherapy)

100% CBT

Blood Transfusions
(In and Out of Hospital)

100% of cost

Radiology In Hospital
Advanced Scans (Mri/Ct/Pet)
Subject to Pre-Authorisation

100% CBT
100% CBT

Pathology
In Hospital

100% Negotiated Rate

Internal Prosthesis
Subject to Pre-Authorisation

100% of cost

Home Nursing
Up to 21 Days, Subject to Pre-Authorisation

100% CBT

Step Down Approved Facilities (Only, up to 90 Days)
Subject to Pre-Authorisation

100% Negotiated Rate

Medication
In Hospital

100% SEP plus dispensing fee

TTO Medication
Up to One Week’s Supply

100% SEP plus dispensing fee

Infertility Treatment
One Cycle per annum

Treatment limited to R55 700 per family

Substance Abuse

PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year,
subject to pre-authorisation and limited to 21 days

Chronic PMB CDL Medication And Treatment - Subject
to Pre-Authorisation and Protocols
Refer to Chronic Disease List

100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

PMB DTP Treatment
Out of Hospital Treatment Subject to Registration of
Condition and Pre-Authorisation

Medication - 100% SEP plus dispensing fee, subject to MMAP and DSP. Consultations and procedures
- at cost

Oncology
Subject to Pre-Authorisation and Icon Protocols#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures
- at 100% Scheme Rate. The ICON Core benefits apply

#Please refer to website for ICON benefit structures

doublePluslogo

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Preventative Wellness Cover 

Camaf Lifestyle Programme
per Adult Beneficiary

INCLUDES: • Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy • Access to e|Care portal with online wellness solutions to monitor your health and promote balanced, healthy living
• Comprehensive wellness report plus personalised health articles in weekly emails when you complete your wellness assessment online.

One Gp Consultation Only
ICD 10 Code Specific to General Check Up Only

100% CBT per beneficiary

One Specialist Consultation
ICD 10 Code Specific to General Check Up Only. Gynaecologists,
Urologists, or Specialist Physicians**
For Beneficiaries over 16 years. Paediatricians for
Beneficiaries under 16 Years

100% CBT per beneficiary

Psychotherapy

100% CBT limited to R10 840 per beneficiary

One Dietician Consultation

100% CBT per beneficiary

One Dentistry Consultation
General Check Up Only - excludes consumables

100% CBT per beneficiary

ONE ECG
(Performed by Gp or Specialist Physician**)
ICD 10 Code Specific to General Check Up Only
- excludes consumables

100% CBT per adult beneficiary

One Optometrist Consultation

Within the PPN Network: 100% of cost for a composite consultation inclusive of the refraction, a
glaucoma screening, and visual field screening. Outside of the PPN Network: 100% Optical Assistant Rates

Metabolic Screening for New Born Babies

100% Negotiated Rate per new born baby

Immunisation and Vaccines
(Cost of Immunisation and Vaccine Only

SEP plus a dispensing fee, limited to: Adults R2 390 - Child R3 970

Cervical Cancer Vaccine
(Cost of Vaccine Only)

Females between 9 and 16 years of age
(SEP plus dispensing fee)

One Hiv Vct Test

100% cost per beneficiary

Melanoma Screening Test

100% CBT per adult beneficiary

Umbilical Stem Cell Harvesting

Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related
to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical
condition. The cash discount that is offered is passed directly on to you and is not paid from your
health plan benefits.

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

doublePluslogo

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Not Subject to the Annual Overall Benefit Limit 

Basic and Advanced Radiology
Out of Hospital
Must be performed by a registered Radiologist, on referral
from medical practitioner only. Advanced scans (mri/ct/pet)
subject to pre-authorisation

100% CBT

Pathology
Out of Hospital
Performed by a registered Pathologist and referred by a
Medical Practitioner
Pre-Authorisation required for Advanced Pathology

100% Negotiated Rate or CBT

Post-Hospitalisation
Consultations and Treatment up to 90 days

300% CBT for attending practitioners
100% CBT for auxiliary services

Medication For Additional Chronic Conditions
(Subject to pre-authorisation) refer to
Additional Chronic Conditions List

100% SEP plus a dispensing fee, subject to RP and DSP
Consultations 100% CBT

External Appliances (subject to referral)
In and out of hospital - purchase, hire and maintenance
Hearing aids - 1 claim per 3 year
Cycle for over 16 years of age, younger than 16 years of age -
18 month cycle
Wheelchairs - 3 year cycle
Insulin pumps, subject to
Pre-authorisation and DSP - 4 year cycle
Breast Pumps and Apnoea Monitors - three months prior to
expected due date and within six months after the birth of the
baby. Subject to registration on the Mother to be Programme

100% NAPPI price or 100% of cost, subject to the overall limit of R63 700 per beneficiary and subject to the following sub-limits:
Hearing Aids: R63 700
Wheelchairs for Quadriplegics: R63 700
Standard Wheelchairs: R40 700
Insulin Pumps: R41 500
Other external appliances: R13 600
• Baby Apnoea monitors: R 2 500
• Breast pumps: R 4 100

International Travel Cover

R10 million per beneficiary per journey for emergency medical costs while you travel outside South
Africa. This cover is for a period of 90 days from your departure from South Africa. Cover for
pre-existing conditions is limited to R150,000 unless additional cover is arranged.

Netcare 911 Emergency Services

Unlimited - Subject to Netcare 911 authorisation

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

doublePluslogo

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Subject to the Annual Overall Day-To-Day Benefit Limit 

Day to Day Benefits
Benefits Below are Subject to the Overall Annual Limit

Annual overall limit:
Adult R11 800
Child R 8 200

Gp’s and Dentists
Dental X-Rays Performed by Dentists,
Consultations And Procedures Performed by these
Practitioners; Basic Dentistry

80% CBT

Specialists
Consultations, Procedures and Radiology Performed by these
Practitioners

80% CBT

Acute Medication
Including Injections and Materials

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA

Casualty and Out Patient Treatment at a Hospital
All Medications will be paid out of Acute Medication Benefit

80% CBT

Nurse Visits

80% CBT up to 21 days

Supplementary Health
Audiology, Chiropractors, Dieticians, Homoeopaths,
Occupational Therapy, Physiotherapists, Biokineticists,
Podiatry and Speech Therapy

80% CBT
BENEFIT SPECIFIC LIMITS

Advanced Dentistry
Crowns, Bridges, Orthodontics, Dentures

80% of CBT limited to:
Mo R11 800
M1 R16 900
M2+ R22 800

Over the Counter Medication

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R1 700 per beneficiary

Laser K
No Approval for Surgery where Spectacles obtained in
previous 12 months
If the Laser K Benefit is utilised, No Spectacle and Contact
Lense Benefit allowed for 2 years

80% CBT limited to R4 430 per beneficiary per eye

Ante-Natal Foetal Scans
per Pregnancy

4 scans at 80% CBT. Subject to limit (c)

Ante-Natal Classes

80% CBT subject to sub-limit R1 754 per pregnancy. Subject to limit (c)

Spectacles and Lenses
from Optometrist Only Annual Benefit, unless otherwise stated

Consultation: See Preventative Wellness Benefit per beneficiary at a PPN PROVIDER:
EITHER: R3 745 for frames and/or lens enhancements and Clear Aquity lenses
OR: Contact lenses to the value of R3 640 PPN Rates apply
Benefit per beneficiary at a NON-PPN PROVIDER, FUNDED AT 80% of Optical
Assistant Rates:
EITHER: R3 745 for frames and/or lens enhancements plus clear lenses. The following sub-limits apply to lenses:
Single vision: R1 020
Bifocal: R2 730
Varifocal: R4 180
OR: Contact lenses to the value of R3 640. Co-payments from MSA. ALL BENEFITS AND CLAIMS MANAGED BY PPN

Monthly Contribution Rates: Double Plus

Monthly Risk ContributionAdult
Child
R3 278
R1 880
Monthly Msa ContributionAdult
Child
R 355
R 225
Total Monthly ContributionAdult
Child
R3 633
R2 105
Benefit Option: Alliance
Any Private Hospital: No limits, private wards for confinements (subject to availability)
Attending Dr’s and Specialists: Up to 300%CBT
64 Chronic Conditions medication and consultations. Includes unlimited appropriate biological drugs and
specialised technology
Unlimited X-Rays and Blood Tests IN and OUT of hospital including MRI and CT scans
Screening Benefits
3 Month Post Hospitalisation Benefit
External Appliances: wheelchair, hearing aid, breast pump, baby sleep monitor
Check-Ups and Vaccines: GP, Specialist, Dental, Optometry, Dermatologist, ECG, Dietician
Infertility R79 700 per family
AllianceLogo

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

In Hospital and Prescribed Minimum Benefits 

Hospital Accommodation
Including Confinements, Subject to Pre-Authorisation

100% of Negotiated Rate in general ward and specialised units

Attending Doctors and Specialists
Consultations

Medical and Surgical Procedures including Confinements
Subject to Pre-Authorisation

Up to 300% CBT
100% of Scheme Rate

Supplementary Healthcare In Hospital
(Eg. Physiotherapy and Psychotherapy)

100% CBT

Blood Transfusions
(In and Out of Hospital)

100% of cost

Radiology In Hospital
Advanced Scans (Mri/Ct/Pet)
Subject to Pre-Authorisation

100% CBT
100% CBT

Pathology
In Hospital

100% Negotiated Rate

Internal Prosthesis
Subject to Pre-Authorisation

100% of cost

Home Nursing
Up to 21 Days, Subject to Pre-Authorisation

100% CBT

Step Down Approved Facilities (Only, up to 90 Days)
Subject to Pre-Authorisation

100% Negotiated Rate

Medication
In Hospital

100% SEP plus dispensing fee

TTO Medication
Up to One Week’s Supply

100% SEP plus dispensing fee

Infertility Treatment
One Cycle per annum

Treatment limited to R79 700 per family

Substance Abuse

PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year,
subject to pre-authorisation and limited to 21 days

Chronic PMB CDL Medication And Treatment - Subject
to Pre-Authorisation and Protocols
Refer to Chronic Disease List

100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at cost

PMB DTP Treatment
Out of Hospital Treatment Subject to Registration of
Condition and Pre-Authorisation

Medication - 100% SEP plus dispensing fee, subject to MMAP and DSP. Consultations and procedures
- at cost

Oncology
Subject to Pre-Authorisation and Icon Protocols#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures
- at 100% Scheme Rate. The ICON Enhanced benefits apply

#Please refer to website for ICON benefit structures

AllianceLogo

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Preventative Wellness Cover 

Camaf Lifestyle Programme
per Adult Beneficiary

INCLUDES: • Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy • Access to e|Care portal with online wellness solutions to monitor your health and promote balanced, healthy living
• Comprehensive wellness report plus personalised health articles in weekly emails when you complete your wellness assessment online.

One Gp Consultation Only
ICD 10 Code Specific to General Check Up Only

100% CBT per beneficiary

One Specialist Consultation
ICD 10 Code Specific to General Check Up Only. Gynaecologists,
Urologists, or Specialist Physicians**
For Beneficiaries over 16 years. Paediatricians for
Beneficiaries under 16 Years

100% CBT per beneficiary

Psychotherapy

100% CBT limited to R10 840 per beneficiary

One Dietician Consultation

100% CBT per beneficiary

One Dentistry Consultation
General Check Up Only - excludes consumables

100% CBT per beneficiary

ONE ECG
(Performed by Gp or Specialist Physician**)
ICD 10 Code Specific to General Check Up Only
- excludes consumables

100% CBT per adult beneficiary

One Optometrist Consultation

Within the PPN Network: 100% of cost for a composite consultation inclusive of the refraction, a
glaucoma screening, and visual field screening. Outside of the PPN Network: 100% Optical Assistant Rates

Metabolic Screening for New Born Babies

100% Negotiated Rate per new born baby

Immunisation and Vaccines
(Cost of Immunisation and Vaccine Only

SEP plus a dispensing fee, limited to R4 780 per beneficiary

Cervical Cancer Vaccine
(Cost of Vaccine Only)

Females between 9 and 16 years of age
(SEP plus dispensing fee)

One Hiv Vct Test

100% cost per beneficiary

Melanoma Screening Test

100% CBT per adult beneficiary

Umbilical Stem Cell Harvesting

Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related
to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical
condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits.

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

AllianceLogo

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Not Subject to the Annual Overall Benefit Limit 

Basic and Advanced Radiology
Out of Hospital
Must be performed by a registered Radiologist, on referral
from medical practitioner only. Advanced scans (mri/ct/pet)
subject to pre-authorisation

100% CBT

Pathology
Out of Hospital
Performed by a registered Pathologist and referred by a
Medical Practitioner
Pre-Authorisation required for Advanced Pathology

100% Negotiated Rate or CBT

Post-Hospitalisation
Consultations and Treatment up to 90 days

300% CBT for attending practitioners
100% CBT for auxiliary services

Medication For Additional Chronic Conditions
(Subject to pre-authorisation) refer to
Additional Chronic Conditions List

100% SEP plus a dispensing fee, subject to RP and DSP
Consultations 100% CBT

External Appliances (subject to referral)
In and out of hospital - purchase, hire and maintenance
Hearing aids - 1 claim per 3 year
Cycle for over 16 years of age, younger than 16 years of age -
18 month cycle
Wheelchairs - 3 year cycle
Insulin pumps, subject to
Pre-authorisation and DSP - 4 year cycle
Breast Pumps and Apnoea Monitors - three months prior to
expected due date and within six months after the birth of the
baby. Subject to registration on the Mother to be Programme

100% NAPPI price or 100% of cost, subject to the overall limit of R79 700 per beneficiary and subject to the following sub-limits:
Hearing Aids: R79 700
Wheelchairs for Quadriplegics: R79 700
Standard Wheelchairs: R47 700
Insulin Pumps: R47 700
Other external appliances: R15 900
• Baby Apnoea monitors: R 2 500
• Breast pumps: R 4 100

International Travel Cover

R10 million per beneficiary per journey for emergency medical costs while you travel outside South
Africa. This cover is for a period of 90 days from your departure from South Africa. Cover for
pre-existing conditions is limited to R150,000 unless additional cover is arranged.

Netcare 911 Emergency Services

Unlimited - Subject to Netcare 911 authorisation

*Refer to website for relevant ICD 10 codes. **Please note that Specialist Physician only refers to the discipline of Specialist Physician and not to subspecialists like
Pulmonologists or Gastroenterologists.

AllianceLogo

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed
by the legislation set out in the Regulations listed in the Medical Schemes Act.

Other Benefits (Per Beneficiary) Subject to the Annual Overall Day-To-Day Benefit Limit 

Day to Day Benefits
Benefits Below are Subject to the Overall Annual Limit

Annual overall limit:
Adult R30 200
Child R18 900

Gp’s and Dentists
Dental X-Rays Performed by Dentists,
Consultations And Procedures Performed by these
Practitioners; Basic Dentistry

80% CBT

Specialists
Consultations, Procedures and Radiology Performed by these
Practitioners

80% CBT

Acute Medication
Including Injections and Materials

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA

Casualty and Out Patient Treatment at a Hospital
All Medications will be paid out of Acute Medication Benefit

80% CBT

Nurse Visits

80% CBT up to 21 days

Supplementary Health
Audiology, Chiropractors, Dieticians, Homoeopaths,
Occupational Therapy, Physiotherapists, Biokineticists,
Podiatry and Speech Therapy

80% CBT
BENEFIT SPECIFIC LIMITS

Advanced Dentistry
Crowns, Bridges, Orthodontics, Dentures

80% of CBT limited to:
Mo R15 800
M1 R23 600
M2+ R28 400

Over the Counter Medication

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R4 000 per beneficiary

Laser K
No Approval for Surgery where Spectacles obtained in
previous 12 months
If the Laser K Benefit is utilised, No Spectacle and Contact
Lense Benefit allowed for 2 years

80% CBT limited to R11 935 per beneficiary per eye

Ante-Natal Foetal Scans
per Pregnancy

6 scans at 80% CBT. Subject to limit (c)

Ante-Natal Classes

80% CBT subject to sub-limit R2 386 per pregnancy

Spectacles and Lenses
from Optometrist Only Annual Benefit, unless otherwise stated

Consultation: See Preventative Wellness Benefit per beneficiary at a PPN PROVIDER:
EITHER: R6 955 for frames and/or lens enhancements and Clear Aquity lenses
OR: Contact lenses to the value of R6 760 PPN Rates apply
Benefit per beneficiary at a NON-PPN PROVIDER, FUNDED AT 80% of Optical
Assistant Rates:
EITHER: R6 955 for frames and/or lens enhancements plus clear lenses. The following sub-limits apply to lenses:
Single vision: R1 550
Bifocal: R3 100
Varifocal: R4 670
OR: Contact lenses to the value of R6 760. Co-payments from MSA. ALL BENEFITS AND CLAIMS MANAGED BY PPN

Monthly Contribution Rates: Alliance

Monthly Risk ContributionAdult
Child
R4 951
R2 696
Monthly Msa ContributionAdult
Child
R 545
R 255
Total Monthly ContributionAdult
Child
R5 496
R2 951
Monthly Contribution Rates
VITALESSENTIAL PLUSNETWORK CHOICEFIRST CHOICEDOUBLE PLUSALLIANCE
Total Monthly Contribution

Income Category - per month

R 0 - R40 000
Adult       R1 935
Child       R 990

R40 001 - R100 000
Adult       R2 150
Child       R1 100

R100 001+
Adult       R2 365
Child       R1 210
Total Monthly Contribution

Income Category - per month

R 0 - R100 000
Principal     R1 580
Adult           R1 250
Child           R 735

Monthly MSA Contribution
Principal     R 500
Adult           R 400
Child           R 235

Total Monthly Contribution
Principal     R2 080
Adult           R1 650
Child             R 970


R100 001+
Principal     R1 892
Adult           R1 498
Child           R 881

Monthly MSA Contribution
Principal     R 500
Adult           R 400
Child           R 235

Total Monthly Contribution
Principal     R2 392
Adult           R1 898
Child           R1 116
Total Monthly Contribution

Income Category - per month

R 0 - R16 440
Principal   R1 375
Adult         R1 150
1st Child   R 598
(rest are free)

R16 441 - R22 050
Principal   R1 635
Adult         R1 305
1st Child   R 735
(rest are free)

R22 051 - R33 080
Principal   R1 956
Adult         R1 515
Child         R 975

R33 081+
Principal   R2 600
Adult         R2 098
Child         R1 277
Total Monthly Contribution

Income Category - per month

R0 - R 8 520
Adult       R 935
Child       R 570

R8 521 - R16 440
Adult       R1 485
Child       R 880

R16 441 - R22 050
Adult       R2 230
Child       R1 297

R22 051 - R33 080
Adult       R2 775
Child       R1 825

R33 081+
Adult       R3 035
Child       R1 980
Monthly Risk Contribution

Adult     R3 278
Child     R1 880

Monthly MSA Contribution
Adult     R 355
Child     R 225

Total Monthly Contribution
Adult     R3 633
Child     R2 105
Monthly Risk Contribution

Adult     R4 951
Child     R2 696

Monthly MSA Contribution
Adult     R 545
Child     R 255

Total Monthly Contribution
Adult     R5 496
Child     R2 951
Chronic Disease List - PMB CDL Conditions - All Options
ConditionConsultationLevel of Consultation Cover
ADDISON’S DISEASEGeneral Practitioner (GP), Physician, Paediatrician100% COST
ASTHMA*GP, Physician, Pulmonologist, Paediatrician, Physiotherapist, subject to clinical protocols100% COST
BIPOLAR MOOD DISORDER*Psychiatrist, Clinical Psychologist, Social Worker100% COST
BRONCHIECTASIS*GP, Physician, Pulmonologist, Physiotherapist100% COST
CARDIAC FAILUREGP, Physician, Cardiologist, Dietician100% COST
CARDIOMYOPATHYGP, Physician, Cardiologist, Dietician100% COST
CHRONIC OBSTRUCTIVE PULMONARY DISORDER (COPD)*GP, Physician, Pulmonologist, Physiotherapist100% COST
CHRONIC RENAL DISEASEGP, Physician100% COST
CORONARY ARTERY DISEASEGP, Physician, Cardiologist, Dietician100% COST
CROHN’S DISEASEGP, Gastroenterologist, Dietician, Physician, General Surgeon100% COST
DIABETES INSIPIDUSGP, Physician, Paediatrician, Endocrinologist100% COST
DIABETES MELLITUS (TYPE 1 AND TYPE 2)*GP, Physician, Paediatrician, Ophthalmologist, Dietician, Podiatrist, Endocrinologist100% COST
DYSRHYTHMIAGP, Physician, Cardiologist, Paediatrician100% COST
EPILEPSYGP, Physician, Neurologist, Occupational Therapist, Speech Therapist, Physiotherapist, Paediatrician100% COST
GLAUCOMAGP, Physician, Ophthalmologist100% COST
HAEMOPHILIA A & BGP, Physician, Paediatrician, Haematologist100% COST
HIV/AIDS**P, Physician, Paediatrician100% COST
HYPERLIPIDAEMIA*GP, Physician, Cardiologist, Paediatrician, Dietician100% COST
HYPERTENSION*GP, Physician, Cardiologist, Dietician100% COST
HYPOTHYROIDISMGP, Physician, Paediatrician100% COST
MULTIPLE SCLEROSISGP, Physician, Neurologist, Ophthalmologist, Urologist, Occupational Therapist, Physiotherapist100% COST
PARKINSON’S DISEASEGP, Physician, Neurologist100% COST
Rheumatoid ArthritisGP, Physician, Rheumatologist, Paediatrician100% COST
SCHIZOPHRENIA*Psychiatrist, Clinical Psychologist, Social Worker100% COST
SYSTEMIC LUPUS ERYTHEMATOSISGP, Physician, Dermatologist, Paediatrician100% COST
ULCERATIVE COLITISGastroenterologist, Dietician, GP, Physician100% COST

In terms of the Medical Schemes Act Regulations that came into effect on 1 January 2004, Medical Schemes are required to fund the cost of the diagnosis, medical management
(consultations and procedures) and medication of the specified list of chronic conditions. All of these conditions are covered by CAMAF
*Subject to registration on relevant Wellness Programme
**Subject to registration with LifeSense

Chronic Disease List - Additional Chronic Conditions - Alliance, Double Plus and Vital options
ConditionConsultationsLevel of Consultation Cover
ADHD (Alliance only)Paediatrician, Neurologist, Psychiatrist100% CBT
ALLERGIC RHINITISGP, Ear Nose and Throat Specialist (ENT), Paediatrician100% CBT
ALZHEIMER’S DISEASENeurologist, Psychiatrist100% CBT
ANKYLOSING SPONDYLITISPhysician, Rheumatologist100% CBT
BENIGN PROSTATIC HYPERTROPHYUrologist100% CBT
CHRONIC GRANULOMATOUS DISEASEPhysician100% CBT
COAGULATION DISORDERSCardiologist, Physician, Clinical Haemotologist100% CBT
CONGENITAL HEART MALFORMATIONSPhysician, Cardiologist, Paediatrician100% CBT
CYSTIC FIBROSISPhysician, Physiotherapist, Pulmonologist, Paediatrician, GP100% CBT
DEEP VEIN THROMBOSISPhysician100% CBT
DEPRESSION (includes First Choice and Essential Plus)GP, Psychiatrist, Clinical Psychologist, Social Worker100% CBT
ECZEMADermatologist, GP100% CBT
ENDOMETRIOSISGynaecologist100% CBT
GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)GP, Gastroenterologist, Physician, Paediatrician100% CBT
GAUCHERS DISEASEPhysician, Paediatrician100% CBT
GOUT PROPHYLAXISGP100% CBT
HORMONE REPLACEMENTGP100% CBT
HYPERPARATHYROIDISMPhysician100% CBT
HYPERTHYROIDISMGP, Paediatrician100% CBT
MENIERE’S DISEASEGP, Ear Nose and Throat Specialist (ENT)100% CBT
MIGRAINE PROPHYLAXISGP, Neurologist100% CBT
MUSCULAR DYSTROPHYNeurologist, Physician, Paediatrician100% CBT
MYASTHENIA GRAVISPhysician100% CBT
NARCOLEPSYNeurologist100% CBT
ORGAN TRANSPLANTAppropriate multi disciplinary team100% CBT
OSTEOARTHRITISPhysician, Rheumatologist, GP100% CBT
OSTEOPOROSISPhysician, Gynaecologist, GP100% CBT
PLEGIA; HEMI, PARA & QUADPhysician, Orthopaedic Surgeon, Physiotherapist, Urologist, Neurologist, Occupational Therapist, Paediatrician, Speech Therapist, GP100% CBT
POLYCYSTIC OVARIAN SYNDROMEGynaecologist100% CBT
PSORIASISDermatologist100% CBT
RESTRICTIVE LUNG DISEASEPulmonologist, Physician100% CBT
TRANSIENT ISCHAEMIC ATTACK / STROKEPhysician, Neurologist100% CBT
TUBERCULOSISGP100% CBT
VALVULAR HEART DISEASEPhysician, Cardiologist, Paediatrician100% CBT
ICD10 Codes 2018
BenefitPractice TypeIcd 10 CodesIcd 10 Description
GP ConsultationGP (14)Z00.0General Medical Examination
Z00.1Routine Child Health Examination
Z00.8Other General Examinations
Z01.3Examination Of Blood Pressure
Z01.4Gynaecological Examination (General)(Routine)
Z10.8Routine General Health Check-Up Of Other Defined Subpopulations
Z12.4Special Screening Examination For Neoplasm Of Cervix
Z12.5Special Screening Examination For Neoplasm Of Prostate
Z13.1Special Screening Examination For Diabetes Mellitus
Z13.6Special Screening Examination For Cardiovascular Disorders
Specialist ConsultationPaediatrician (32)Z00.0General Medical Examination
Z00.1Routine Child Health Examination
Z00.8Other General Examinations
Z10.8Routine General Health Check-Up Of Other Defined Subpopulations
Specialist ConsultationGynaecologist (16)Z00.0General Medical Examination
Specialist Physician (18)Z00.8Other General Examinations
Urologist (46)Z01.3Examination Of Blood Pressure
Z01.4Gynaecological Examination (General)(Routine)
Z10.8Routine General Health Check-Up Of Other Defined Subpopulations
Z12.4Special Screening Examination For Neoplasm Of Cervix
Z12.5Special Screening Examination For Neoplasm Of Prostate
Z13.1Special Screening Examination For Diabetes Mellitus
Z13.6Special Screening Examination For Cardiovascular Disorders
Melanoma ScreeningDermatologist (12)Z12.8Special Screening Examination for Neoplasm of other sites
Z12.9Special Screening Examination for Neoplasm, unspecified
D22.0Melanocytic naevi of lip
D22.1Melanocytic naevi of eyelid, including canthus
D22.2Melanocytic naevi of ear and external auricular canal
D22.3Melanocytic naevi of other and unspecified parts of face
D22.4Melanocytic naevi of scalp and neck
D22.5Melanocytic naevi of trunk
D22.6Melanocytic naevi of upper limb, including shoulder
D22.7Melanocytic naevi of lower limb, including hip
D22.9Melanocytic naevi, unspecified
CAMAF Benefit Option 2018 - Pdf Download
Glossary

*More details available on the website www.camaf.co.za
– for full explanations, consult the Registered Rules

ADULTRefers to the member and dependants who are 22 or older at any time in the year of cover.
CBTCAMAF Base Tariff - the maximum rate paid by the Scheme to providers of healthcare services, based on 2009 RPL (Medical Aid) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options.
CDLChronic Disease List - the list of PMB’s includes 25 common chronic conditions called CDL’s. Schemes must provide cover for the diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s).
CML/ FORMULARYCondition Medicine List - once a patient’s chronic condition has been registered, a patient will have access to the CML. This is a list of drugs, appropriate for the condition, that do not require authorisation. This is maintained by the Scheme and differs per Option. Reference pricing may still apply.
CHILDRefers to a dependant who is younger than an adult, as defined above.
DISPENSING FEESFee negotiated by the Scheme with Network pharmacies and added to SEP.
DSPThe network of service providers contracted to provide healthcare services to members, eg. Independent Clinical Oncology Network (ICON), HIV programme (LifeSense), PPN for optical benefits, Pharmacy networks for all chronic medications, Netcare 911 for emergency transport and Netcare hospital group for Network Choice hospital admissions.
DTPThe Regulations to the Medical Schemes Act in Annexure A provide a list of conditions identified as Prescribed Minimum Benefits. The List is in the form of Diagnosis Treatment Pairs (DTP’s). A DTP links a specific diagnosis to a treatment/procedure and therefore broadly indicates how each of the 270 PMB conditions should be treated. These treatment pairs cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s).
ICD 10 CODEStands for International Classification of Diseases and Related Health Problems (10th revision). It is a coding system developed by the World Health Organisation (WHO) that translates the written description of medical and health information into standard codes, e.g. J03.9 is an ICD-10 code for acute tonsillitis (unspecified) and G40.9 denotes epilepsy (unspecified). These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be paid from the correct benefit.
INCOMETotal cost to company prior to deductions.
MEDICAL SAVINGS ACCOUNTA savings account that accrues monthly but the annualised amount of savings is available immediately and can be used for: • top up on cost of service charged by a doctor • extension when an overall benefit has been exceeded • exclusion from benefits • payment of day to day claims on Essential Plus option
METABOLIC SCREENINGNewborn screening whereby rare disorders are detected by a blood test done 48 - 72 hours after birth.
MMAPMaximum Medical Aid Price - is a reference price model and determines the maximum medical scheme price that medical schemes will reimburse for an interchangeable multi-source pharmaceutical product (generic) on the relevant option. MMAP applies to all options for chronic medication.
NEGOTIATED RATEThis is the rate, negotiated by the scheme with the service provider/group of service providers, eg. hospitals and pathologists.
PMBPrescribed Minimum Benefits - as set out in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the diagnosis, treatment and care of: • Any emergency medical condition • A limited set of 270 medical conditions (Defined in DTP’s) • 25 chronic conditions defined in the CDL • These costs may not be paid from the member’s savings benefit and cost saving measures can be used by way of utilising DSP’s, Reference Pricing and Formularies.
PRE-AUTHORISATIONA member must obtain prior approval for an intended admission to hospital. Failure to pre-authorise could result in wholly or partly disallowing the claim or imposing a penalty of 20% of related accounts up to a maximum of R 2 500. Emergency treatment is not subject to Pre-authorisation but members should notify the Scheme as soon as possible after the event.
PROTOCOLMeans a set of guidelines in relation to diagnostic testing and management of specific conditions and includes, but is not limited to, clinical practice guidelines, standard treatment guidelines and disease management guidelines.
RISK CONTRIBUTIONSThose funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account.
RPReference Pricing is the maximum price for which the Scheme will be liable for specific medicine or classes of medicine, listed on the Scheme’s Condition Medicine List (CML). The reference price varies per option and where a drug is above the reference price it is indicated that a co-payment will apply. This includes MMAP.
SCHEME RATEThe maximum rate paid by the scheme to providers of healthcare services, based on SAMA (Private) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options.
SEPSingle Exit Price - nationally applied pricing for medication as determined by the Department of Health and the pharmaceutical manufacturers.
TTO“To Take Out” - medication supplied by the hospital for use after the date of discharge from hospital - limited to a 7 day supply.

CAMAF BENEFIT OPTION 2018 – PDF DOWNLOAD

Facebook Iconfacebook like buttonTwitter Icontwitter follow buttonLinkedinLinkedin
Thanks!

Please note that our web chat operating hours

are Mondays to Fridays 9:00am-3:00pm,

excluding public holidays.

Please feel free to also contact us on custserv@camaf.co.za

Register