CAMAF Benefit Brochure 2020

This brochure is for summary purposes only and does not supersede the rules of the Scheme in any way.

CAMAF BENEFIT OPTION 2020 – PDF DOWNLOAD

CAMAF Benefit Option Summary
Alliance Double Plus Vital Essential Plus First Choice Network Choice
Hospital and Chronic ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆ ☆☆☆ ☆☆☆
Day to Day ☆☆☆☆☆ ☆☆☆☆ ☆☆☆ ☆☆☆
Preventative Wellness Benefits ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆ ☆☆☆
MSA (savings) ☆☆☆☆ ☆☆☆ ☆☆☆☆☆
Target Market Executives, mature families and members with significant health risks. Young families or couples trying to conceive. Single members or couples without children in need of major risks covered. Entry to mid-level wanting to put away savings for day-day expenses. Entry-level and suport staff at member firms. Entry-level and support staff willing to make use of networks.
CAMAF Benefit Options: Quick Summary
 AllianceDouble PlusVitalEssential PlusFirst ChoiceNetwork Choice
Hospital Facility FeesAny private hospital.
Private wards
Any private hospitalAny private hospitalAny private hospitalAny private hospitalNetcare hospitals only
Attending Doctor’s and Specialists in HospitalUp to 300% CBTUp to 300% CBTUp to 300% CBTUp to 200% CBTUp to 100% CBTUp to 100% CBT
Chronic condition cover: medicines and consults64 Conditions63 Conditions63 Conditions27 Conditions27 Conditions27 Conditions
Radiology and PathologyUnlimited In or Out of HospitalUnlimited In or Out of HospitalUnlimited In or Out of HospitalUnlimited In Hospital,
Out of Hospital from MSA
Limits apply In and Out of HospitalLimits apply In and Out of Hospital
Preventative Wellness Benefits14 extra benefits14 extra benefits14 extra benefits14 extra benefits10 extra benefits10 extra benefits
Day to Day Overall Limit (Principal Member)R34 100R13 261--R3 190 for Medicines.
R9 830 for Specialists.
R3 190 for Other.
Paid at 80%
R3 190 for Medicines.
R9 830 for Specialists.
R3 190 for Other.
From DSP only
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 Benefit
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 R87 000 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. Private ward for confinements (subject to availability)

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/PHYSICAL REHABILITATION 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

Treatment limited to R87 000 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 - as per PMB regulations

PMB DTP TREATMENT
OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF CONDITION AND PRE-AUTHORISATION

Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP.
Consultations and procedures - as per PMB regulations

ONCOLOGY
SUBJECT TO PREAUTHORISATION 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 PREVENTATIVE PROGRAMME
PER ADULT BENEFICIARY

INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy

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 18 YEARS. PAEDIATRICIANS FOR BENEFICIARIES UNDER 18 YEARS

100% CBT per beneficiary

PSYCHOTHERAPY

100% CBT limited to R12 300 per beneficiary

ONE DIETICIAN CONSULTATION

100% CBT per beneficiary

ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY

100% CBT per beneficiary

ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN)
*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per adult beneficiary

ONE OPTOMETRIST CONSULTATION

100% Optical Assistant Rates

IMMUNISATION AND VACCINES
(COST OF IMMUNISATION AND VACCINE ONLY)

SEP plus a dispensing fee,
limited to R5 310 per beneficiary

CERVICAL CANCER VACCINE (HPV)
(COST OF VACCINE ONLY - SUBJECT TO IMMUNISATION AND VACCINES BENEFIT)

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

ONE HIV VCT TEST

100% CBT per beneficiary

MELANOMA SCREENING

100% CBT per adult beneficiary

*Refer to website for relevant ICD 10 codes.

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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
INCLUDING CONFINEMENTS,
SUBJECT TO PRE-AUTHORISATION

See In Hospital and Prescribed Minimum Benefits above

EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES
LIMIT
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

Baby Apnoea Monitors: R2 750
Breast pumps: R4 500

METABOLIC SCREENING FOR NEW BORN BABIES

100% Negotiated Rate per new born baby

ANTE-NATAL FOETAL SCANS PER PREGNANCY

6 scans at 80% CBT
Subject to Annual Overall Day-to-Day Limit

ANTE-NATAL CLASSES

80% CBT limited to R2 630 per pregnancy
Subject to Annual Overall Day-to-Day Limit

UMBLICAL 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.
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 supplementary 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 (subject to pre-authorisation)
- 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 (rent to own over 12 months), SUBJECT TO
PRE-AUTHORISATION AND DSP - 4 YEAR CYCLE

100% NAPPI price or 100% of cost, subject to the overall limit of R87 800 per beneficiary and subject
to the following sub-limits:
Hearing Aids: R87 800
Wheelchairs for
Quadriplegics: R87 800
Standard Wheelchairs: R52 500
Insulin Pumps: R52 500
Other external appliances: R17 400

INTERNATIONAL TRAVEL COVER
PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND
SUBJECT TO THEIR POLICY REQUIREMENTS.
ARRANGE COVER PRIOR TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS.

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
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 BENEFIT LIMIT

DAY TO DAY BENEFITS
BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT

Annual Overall Limits
Adult R34 100
Child R21 300

GPs 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 dispensing fee, subject to MMAP, co-payment from MSA

NON-DSP VISITS
TO DOCTOR’S ROOMS

Not applicable

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL
ALL MEDICATION 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

ADVANCED DENTISTRY
CROWNS, BRIDGES, ORTHODONTICS, DENTURES

80% CBT limited to:
M0 R17 400
M1 R26 000
M2+ R31 300

OVER THE COUNTER MEDICATION

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to
R4 400 per beneficiary

LASER K/EXCIMER LASER
NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN
PREVIOUS 12 MONTHS

80% CBT limited to R13 155 per beneficiary per eye

SPECTACLES AND LENSES
FROM OPTOMETRIST ONLY
ANNUAL BENEFIT, UNLESS OTHERWISE STATED

Consultation: See Preventative Wellness Benefit
Add ons R1 710
Single vision R1 710 OR
Bifocal R3 420 OR
Varifocal R5 150 AND
Frames R7 670 OR
Contact lenses R7 460
Lenses, frames etc 80% Optical Assistant Rates

Monthly Contribution Rates: Alliance

Monthly Risk ContributionAdult
Child
R5 924
R3 216
Monthly MSA ContributionAdult
Child
R   575
R   270
Total Monthly ContributionAdult
Child
R6 499
R3 486
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 R61 400 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/PHYSICAL REHABILITATION 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

Treatment limited to R61 400 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 -
as per PMB regulations

PMB DTP TREATMENT
OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF
CONDITION AND PRE-AUTHORISATION

Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP.
Consultations and procedures - as per PMB regulations

ONCOLOGY
SUBJECT TO PREAUTHORISATION 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 PREVENTATIVE PROGRAMME
PER ADULT BENEFICIARY

INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy

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 18 YEARS. PAEDIATRICIANS FOR
BENEFICIARIES UNDER 18 YEARS

100% CBT per beneficiary

PSYCHOTHERAPY

100% CBT limited to R12 300 per beneficiary

ONE DIETICIAN CONSULTATION

100% CBT per beneficiary

ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY

100% CBT per beneficiary

ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN)
*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per adult beneficiary

ONE OPTOMETRIST CONSULTATION

100% Optical Assistant Rates

IMMUNISATION AND VACCINES
(COST OF IMMUNISATION AND VACCINE ONLY)

SEP plus a dispensing fee,
limited to: Adults R2 660 - Child R4 410

CERVICAL CANCER VACCINE (HPV)
(COST OF VACCINE ONLY - SUBJECT TO IMMUNISATION AND
VACCINES BENEFIT)

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

ONE HIV VCT TEST

100% CBT per beneficiary

MELANOMA SCREENING

100% CBT per adult beneficiary

*Refer to website for relevant ICD 10 codes.

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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
INCLUDING CONFINEMENTS,
SUBJECT TO PRE-AUTHORISATION

See In Hospital and Prescribed Minimum Benefits above

EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES
LIMIT
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

Baby Apnoea Monitors: R2 700
Breast pumps: R4 500

METABOLIC SCREENING FOR NEW BORN BABIES

100% Negotiated Rate per new born baby

ANTE-NATAL FOETAL SCANS PER PREGNANCY

4 scans at 80% CBT
Subject to Annual Overall Day-to-Day Limit

ANTE-NATAL CLASSES

80% CBT limited to R1 925 per pregnancy
Subject to Annual Overall Day-to-Day Limit

UMBLICAL 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.
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 supplementary 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 (subject to pre-authorisation) -
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 (rent to own over 12 months), SUBJECT TO
PRE-AUTHORISATION AND DSP - 4 YEAR CYCLE

100% NAPPI price or 100% of cost, subject to the overall limit of R70 200 per beneficiary
and subject to the following sub-limits:
Hearing Aids: R70 200
Wheelchairs for
Quadriplegics: R70 200
Standard Wheelchairs: R44 800
Insulin Pumps: R45 800
Other external appliances: R15 000

INTERNATIONAL TRAVEL COVER
PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND
SUBJECT TO THEIR POLICY REQUIREMENTS. ARRANGE COVER PRIOR
TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS.

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
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 BENEFIT LIMIT

DAY TO DAY BENEFITS
BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT

Annual Overall Limits
Adult R13 261
Child R 9 215

GPs 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 dispensing fee, subject to MMAP, co-payment from MSA

NON-DSP VISITS
TO DOCTOR’S ROOMS

Not applicable

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL
ALL MEDICATION 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

ADVANCED DENTISTRY
CROWNS, BRIDGES, ORTHODONTICS, DENTURES

80% CBT limited to:
M0 R12 900
M1 R18 600
M2+ R25 000

OVER THE COUNTER MEDICATION

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to
R1 900 per beneficiary

LASER K/EXCIMER LASER
NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN
PREVIOUS 12 MONTHS

80% CBT limited to R4 860 per beneficiary per eye

SPECTACLES AND LENSES
FROM OPTOMETRIST ONLY
ANNUAL BENEFIT, UNLESS OTHERWISE STATED

Consultation: See Preventative Wellness Benefit
Add ons R1 120
Single vision R1 120 OR
Bifocal R2 990 OR
Varifocal R4 590 AND
Frames R4 129 OR
Contact lenses R4 013
Lenses, frames etc 80% Optical Assistant Rates

Monthly Contribution Rates: Double Plus

Monthly Risk ContributionAdult
Child
R3 918
R2 246
Monthly MSA ContributionAdult
Child
R   375
R   240
Total Monthly ContributionAdult
Child
R4 293
R2 486
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 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/PHYSICAL REHABILITATION 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 -
as per PMB regulations

PMB DTP TREATMENT
OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF
CONDITION AND PRE-AUTHORISATION

Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP.
Consultations and procedures - as per PMB regulations

ONCOLOGY
SUBJECT TO PREAUTHORISATION 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 PREVENTATIVE PROGRAMME
PER ADULT BENEFICIARY

INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy

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 18 YEARS. PAEDIATRICIANS FOR
BENEFICIARIES UNDER 18 YEARS

100% CBT per beneficiary

PSYCHOTHERAPY

100% CBT limited to R12 300 per beneficiary

ONE DIETICIAN CONSULTATION

100% CBT per beneficiary

ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY

100% CBT per beneficiary

ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN)
*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per adult beneficiary

ONE OPTOMETRIST CONSULTATION

100% Optical Assistant Rates

IMMUNISATION AND VACCINES
(COST OF IMMUNISATION AND VACCINE ONLY)

SEP plus a dispensing fee, limited to R1 767 per beneficiary

CERVICAL CANCER VACCINE (HPV)
(COST OF VACCINE ONLY - SUBJECT TO IMMUNISATION AND
VACCINES BENEFIT)

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

ONE HIV VCT TEST

100% CBT per beneficiary

MELANOMA SCREENING

100% CBT per adult beneficiary

*Refer to website for relevant ICD 10 codes.

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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
INCLUDING CONFINEMENTS,
SUBJECT TO PRE-AUTHORISATION

See In Hospital and Prescribed Minimum Benefits above

EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES
LIMIT
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

Baby Apnoea Monitors: R2 700
Breast pumps: R4 500

METABOLIC SCREENING FOR NEW BORN BABIES

100% Negotiated Rate per new born baby

UMBLICAL 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.
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 supplementary 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 (subject to pre-authorisation) -
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 (rent to own over 12 months), SUBJECT TO
PRE-AUTHORISATION AND DSP - 4 YEAR CYCLE

100% NAPPI price or 100% of cost, subject to the overall limit of R40 400 per beneficiary and
subject to the following sub-limits:
Hearing Aids: R35 100
Wheelchairs for
Quadriplegics: R35 100
Standard Wheelchairs: R24 700
Insulin Pumps: R40 400
Other external appliances: R 8 800

INTERNATIONAL TRAVEL COVER
PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND
SUBJECT TO THEIR POLICY REQUIREMENTS . ARRANGE COVER
PRIOR TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS.

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

Monthly Contribution Rates: Vital

Monthly income based on
Total Cost to Company of
Principal Member
 Total Monthly Contribution
R0 - R44 520Adult
Child
R2 295
R1 177
R44 521 - R111 300Adult
Child
R2 602
R1 328
R111 301+Adult
Child
R2 886
R1 478
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
Check-ups 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 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 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
Exclusions: cochlear implants

HOME NURSING
UP TO 21 DAYS, SUBJECT TO PRE AUTHORISATION

100% CBT

STEP-DOWN/PHYSICAL REHABILITATION 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 - as per PMB regulations

PMB DTP TREATMENT
OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF
CONDITION AND PRE-AUTHORISATION

Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP.
Consultations and procedures - as per PMB regulations

ONCOLOGY
SUBJECT TO PREAUTHORISATION AND ICON PROTOCOLS#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and
procedures - 100% DSP Tariff
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 PREVENTATIVE PROGRAMME
PER ADULT BENEFICIARY

INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy

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 18 YEARS. PAEDIATRICIANS FOR
BENEFICIARIES UNDER 18 YEARS

100% CBT per beneficiary

PSYCHOTHERAPY

100% CBT limited to R12 300 per beneficiary

ONE DIETICIAN CONSULTATION

100% CBT per beneficiary

ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY

100% CBT per beneficiary

ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN)
*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per beneficiary

ONE OPTOMETRIST CONSULTATION

100% Optical Assistant Rates

IMMUNISATION AND VACCINES
(COST OF IMMUNISATION AND VACCINE ONLY)

SEP plus a dispensing fee, limited to R1 767 per beneficiary

CERVICAL CANCER VACCINE (HPV)
(COST OF VACCINE ONLY - SUBJECT TO IMMUNISATION AND
VACCINES BENEFIT)

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

ONE HIV VCT TEST

100% CBT per beneficiary

MELANOMA SCREENING

100% CBT per adult beneficiary

*Refer to website for relevant ICD 10 codes.

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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
INCLUDING CONFINEMENTS,
SUBJECT TO PRE-AUTHORISATION

See In Hospital and Prescribed Minimum Benefits

EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES
LIMIT
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

METABOLIC SCREENING FOR NEW BORN BABIES

100% Negotiated Rate per new born baby

ANTE-NATAL FOETAL SCANS PER PREGNANCY

Subject to Medical Savings Account

ANTE-NATAL CLASSES

Subject to Medical Savings Account

UMBLICAL 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.
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 (subject to pre-authorisation) -
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 (rent to own over 12 months), SUBJECT TO
PRE-AUTHORISATION AND DSP - 4 YEAR CYCLE/p>

Subject to Medical Savings Account

INTERNATIONAL TRAVEL COVER
PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND
SUBJECT TO THEIR POLICY REQUIREMENTS . ARRANGE COVER
PRIOR TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS.

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
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 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 MEDICATION 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

BENEFIT SPECIFIC LIMITS

ADVANCED DENTISTRY
CROWNS, BRIDGES, ORTHODONTICS, DENTURES

Subject to Medical Savings Account

OVER THE COUNTER MEDICATION

Subject to Medical Savings Account

LASER K/EXCIMER LASER
NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN
PREVIOUS 12 MONTHS

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

Monthly income based on
Total Cost to Company of
Principal Member
 Total Monthly Contribution
R0 - R111 300Principal
Adult
Child
R1 885
R1 490
R   875
Monthly MSA ContributionPrincipal
Adult
Child
R 570
R 455
R 270
Total Monthly ContributionPrincipal
Adult
Child
R2 455
R1 945
R1 145
R111 301+Principal
Adult
Child
R2 265
R1 795
R1 050
Monthly MSA ContributionPrincipal
Adult
Child
R 570
R 455
R 270
Total Monthly ContributionPrincipal
Adult
Child
R2 835
R2 250
R1 320
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 R36 900 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% 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% CBT limited to R36 900 per family

PATHOLOGY IN HOSPITAL

100% CBT

INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION

100% of cost limited to R36 900 per family
Exclusions: cochlear implants

HOME NURSING
UP TO 21 DAYS, SUBJECT TO PRE AUTHORISATION

100% CBT (in lieu of hospitalisation only)

STEP-DOWN/PHYSICAL REHABILITATION 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 -
as per PMB regulations

PMB DTP TREATMENT
OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF
CONDITION AND PRE-AUTHORISATION

Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP.
Consultations and procedures - as per PMB regulations

ONCOLOGY
SUBJECT TO PREAUTHORISATION AND ICON PROTOCOLS#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and
procedures - 100% DSP Tariff
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 PREVENTATIVE PROGRAMME
PER ADULT BENEFICIARY

INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy

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 18 YEARS. PAEDIATRICIANS FOR
BENEFICIARIES UNDER 18 YEARS

100% CBT per beneficiary

PSYCHOTHERAPY

100% CBT limited to R12 300 per beneficiary

ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY

100% CBT per beneficiary

ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN)
*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per adult beneficiary

ONE OPTOMETRIST CONSULTATION

Refer to spectacle and lenses benefits

IMMUNISATION AND VACCINES
(COST OF IMMUNISATION AND VACCINE ONLY)

SEP plus a dispensing fee, subject to MMAP, limited to R1 767 per beneficiary

CERVICAL CANCER VACCINE (HPV)
(COST OF VACCINE ONLY - SUBJECT TO IMMUNISATION AND
VACCINES BENEFIT)

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

ONE HIV VCT TEST

100% CBT per beneficiary

*Refer to website for relevant ICD 10 codes.

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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
INCLUDING CONFINEMENTS,
SUBJECT TO PRE-AUTHORISATION

See In Hospital and Prescribed Minimum Benefits

EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES
LIMIT
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

Baby Apnoea Monitors: R2 200
Breast pumps: R3 800

METABOLIC SCREENING FOR NEW BORN BABIES

100% Negotiated Rate per new born baby

ANTE-NATAL FOETAL SCANS PER PREGNANCY

3 scans at 80% CBT. Subject to limit (c) of Annual Overall Day-to-Day Benefit Limit

ANTE-NATAL CLASSES

80% CBT subjects to sub-limit R1 020 per pregnancy.
Subject to limit (c) of Annual Overall Day-to-Day Benefit Limit

UMBLICAL 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.

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 310 per beneficiary
Advanced scans: 100% CBT limited to R36 900 per family

PATHOLOGY
OUT OF HOSPITAL
PERFORMED BY
A REGISTERED PATHOLOGIST AND REFERRED BY
A MEDICAL PRACTITIONER
PRE-AUTHORISATION REQUIRED FOR ADVANCED PATHOLOGY

100% Negotiated Rate limited to R6 880 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 (subject to pre-authorisation) -
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 (rent to own over 12 months), SUBJECT TO
PRE-AUTHORISATION AND DSP - 4 YEAR CYCLE

100% NAPPI price or 100% of cost, in hospital and 80% of cost out of hospital with an overall
limit of R6 600 per beneficiary

INTERNATIONAL TRAVEL COVER
PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND
SUB JECT TO THEIR POLICY REQUIREMENTS . ARRANGE COVER
PRIOR TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS.

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

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 BENEFIT LIMIT

DAY TO DAY BENEFITS
BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT

Annual overall limit: Beneficiary specific limits:
(a) Medicines R3 190
(b) Advanced Dentistry R6 690
(c) Other R3 190
(d) Specialists R9 830

GP's AND DENTISTS
DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS
AND PROCEDURES PERFORMED BY THESE PRACTITIONERS;
BASIC DENTISTRY

80% CBT
Subject to limit (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 MEDICATION 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 subject to sub-limit R2 680
Subject to limit (c)

BENEFIT SPECIFIC LIMITS

ADVANCED DENTISTRY
CROWNS, BRIDGES, ORTHODONTICS, DENTURES

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

OVER THE COUNTER MEDICATION

50% SEP plus a dispensing fee, subject to MMAP, limited to R1 640 per beneficiary. Subject to limit (a)

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 R750 off any alternative frame
and/or lens enhancements and one pair of lenses: either One pair of Clear A quity Single Vision;
Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R840.
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 R300 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 R410 per lens or one pair of clear flat top Multifocal lenses limited to R710 per lens OR CONTACT LENSES -
Contact Lenses to the value of R840.

Monthly Contribution Rates: First Choice

Monthly income based on
Total Cost to Company of
Principal Member
 Total Monthly Contribution
R0 - R9 490Adult
Child
R1 131
R   689
R9 491 - R18 300Adult
Child
R1 796
R1 064
R18 301 - R24 540Adult
Child
R2 697
R1 568
R24 541 - R36 810Adult
Child
R3 356
R2 207
R36 811+Adult
Child
R3 670
R2 395
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 R36 900 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% 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% 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% CBT limited to R36 900 per family

PATHOLOGY IN HOSPITAL

100% CBT

INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION

100% of cost limited to R36 900 per family
Exclusions: cochlear implants

HOME NURSING
UP TO 21 DAYS, SUBJECT TO PRE AUTHORISATION

100% CBT (in lieu of hospitalisation only)

STEP-DOWN/PHYSICAL REHABILITATION 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 -
as per PMB regulations

PMB DTP TREATMENT
OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF
CONDITION AND PRE-AUTHORISATION

Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP.
Consultations and procedures - as per PMB regulations

ONCOLOGY
SUBJECT TO PREAUTHORISATION AND ICON PROTOCOLS#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and
procedures - 100% DSP Tariff
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 PREVENTATIVE PROGRAMME
PER ADULT BENEFICIARY

INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy

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 18 YEARS. PAEDIATRICIANS FOR
BENEFICIARIES UNDER 18 YEARS

100% CBT per beneficiary

PSYCHOTHERAPY

100% CBT limited to R12 300 per beneficiary

ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY

100% CBT per beneficiary

ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN)
*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per adult beneficiary

ONE OPTOMETRIST CONSULTATION

Refer to spectacle and lenses benefits

IMMUNISATION AND VACCINES
(COST OF IMMUNISATION AND VACCINE ONLY)

SEP plus a dispensing fee, subject to MMAP, limited to R1 767 per beneficiary

CERVICAL CANCER VACCINE (HPV)
(COST OF VACCINE ONLY - SUBJECT TO IMMUNISATION AND
VACCINES BENEFIT)

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

ONE HIV VCT TEST

100% CBT per beneficiary

*Refer to website for relevant ICD 10 codes.

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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
INCLUDING CONFINEMENTS,
SUBJECT TO PRE-AUTHORISATION

See In Hospital and Prescribed Minimum Benefits

EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES
LIMIT
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

Baby Apnoea Monitors: R2 200
Breast pumps: R3 800

METABOLIC SCREENING FOR NEW BORN BABIES

100% Negotiated Rate per new born baby

ANTE-NATAL FOETAL SCANS PER PREGNANCY

3 scans at 80% CBT. Subject to limit (c) of Annual Overall Day-to-Day Benefit Limit

ANTE-NATAL CLASSES

80% CBT subjects to sub-limit R1 020 per pregnancy.
Subject to limit (c) of Annual Overall Day-to-Day Benefit Limit

UMBLICAL 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.

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 310 per beneficiary
Advanced scans: 100% CBT limited to R36 900 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% Negotiated Rate, limited to R6 880 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 (subject to pre-authorisation)
- 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 (rent to own over 12 months), SUBJECT TO
PRE-AUTHORISATION AND DSP - 4 YEAR CYCLE

100% NAPPI price or 100% of cost, limited to R6 600 per beneficiary and subject to DSP or Specialist referral

INTERNATIONAL TRAVEL COVER
PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND
SUB JECT TO THEIR POLICY REQUIREMENTS . ARRANGE
COVER PRIOR TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS.

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

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

DAY TO DAY BENEFITS
BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT

Annual overall limit: Beneficiary specific limits:
(a) Medicines R3 190
(b) Advanced Dentistry R6 690
(c) Other R3 190
(d) Specialists R9 830

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 DOCTOR’S ROOMS

One non-network visit per beneficiary or two per family, 20% co-payment
AND
One casualty visit per family (facility fee, consumed meds and materials).
Limited to R 1 376

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 680 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

50% SEP plus a dispensing fee, subject to MMAP, limited to R1 640 per beneficiary. Subject to limit (a)

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 R750 off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear A quity Single Vision; Clear Aquity Bifocal
lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R840.
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 R300 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 spectacl e lenses limited to R175 per lens or one pair
of clear flat top bifocal spectacle lenses limited to R410 per lens or one pair of clear flat top Multifocal
lenses limited to R710 per lens OR CONTACT LENSES - Contact Lenses to the value of R840.

Monthly Contribution Rates: Network Choice

Monthly income based on
Total Cost to Company of
Principal Member
 Total Monthly Contribution
R0 - R18 300Principal
Adult
1st Child
(rest are free)
R1 611
R1 347
R   701
R18 301 - R24 540Principal
Adult
1st Child
(rest are free)
R1 915
R1 529
R   861
R24 541 - R36 810Principal
Adult
Child
R2 291
R1 775
R1 142
R36 811+Principal
Adult
Child
R3 046
R2 458
R1 496
Monthly Contribution Rates
ALLIANCEDOUBLE PLUSVITALESSENTIAL PLUSFIRST CHOICENETWORK CHOICE
Monthly Risk Contribution

Adult     R5 924
Child     R3 216

Monthly MSA Contribution
Adult     R 575
Child     R 270

Total Monthly Contribution
Adult     R6 499
Child     R3 486
Monthly Risk Contribution

Adult     R3 918
Child     R2 246

Monthly MSA Contribution
Adult     R 375
Child     R 240

Total Monthly Contribution
Adult     R4 293
Child     R2 486
Monthly income based on
Total Cost to Company of
Principal Member


Total Monthly Contribution
R 0 - R44 520
Adult       R2 295
Child       R1 177

R44 521 - R111 300
Adult       R2 602
Child       R1 328

R111 301+
Adult       R2 886
Child       R1 478
Monthly income based on
Total Cost to Company of
Principal Member


Total Monthly Contribution
R 0 - R111 300
Principal     R1 885
Adult           R1 490
Child           R 875

Monthly MSA Contribution
Principal     R 570
Adult           R 455
Child           R 270

Total Monthly Contribution
Principal     R2 455
Adult           R1 945
Child           R1 145


R111 301+
Principal     R2 265
Adult           R1 795
Child           R1 050

Monthly MSA Contribution
Principal     R 570
Adult           R 455
Child           R 270

Total Monthly Contribution
Principal     R2 835
Adult           R2 250
Child           R1 320
Monthly income based on
Total Cost to Company of
Principal Member


Total Monthly Contribution
R0 - R9 490
Adult       R1 131
Child       R 689

R9 491 - R18 300
Adult       R1 796
Child       R1 064

R18 301 - R24 540
Adult       R2 697
Child       R1 568

R24 541 - R36 810
Adult       R3 356
Child       R2 207

R36 811+
Adult       R3 670
Child       R2 395
Monthly income based on
Total Cost to Company of
Principal Member


Total Monthly Contribution
R 0 - R18 300
Principal   R1 611
Adult         R1 347
1st Child   R 701
(rest are free)

R18 301- R24 540
Principal   R1 915
Adult         R1 529
1st Child   R 861
(rest are free)

R24 541 - R36 810
Principal   R2 291
Adult         R1 775
Child         R1 142

R36 811+
Principal   R3 046
Adult         R2 458
Child         R1 496
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**GP, 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 2020
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 2020 - 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 2020 – PDF DOWNLOAD

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