CAMAF Benefit Brochure 2022

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

CAMAF BENEFIT OPTION 2022 – 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 support staff at member firms. Entry-level and support staff willing to make use of networks.
CAMAF Benefit Options: Quick Summary
 Alliance Plus
Alliance Network
Double Plus
Double Network
Vital Plus
Vital Network
Essential Plus
Essential Network
First ChoiceNetwork Choice
Hospital Facility FeesAlliance Plus
Any private hospital. Private wards.

Alliance Network
Life Healthcare, Netcare. Private wards.
Double Plus
Any private hospital.


Double Network
Life Healthcare, Netcare.
Vital Plus
Any private hospital.


Vital Network
Life Healthcare, Netcare.
Essential Plus
Any private hospital.


Essential Network
Life Healthcare, Netcare.
Any private hospitalNetcare hospitals only
Attending Doctor’s and Specialists in Hospital300% CBT300% CBT300% CBT200% CBT100% CBT100% CBT
Chronic condition cover: medicines and consults64 Conditions
List of conditions
Additional conditions
63 Conditions
List of conditions
Additional conditions
63 Conditions
List of conditions
Additional conditions
27 Conditions
List of conditions
27 Conditions
List of conditions
27 Conditions
List of 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)R36 600R14 233--R3 430 for Medicines.
R10 550 for Specialists.
R3 430 for Other.
Paid at 80%
R3 430 for Medicines.
R10 550 for Specialists.
R3 430 for Other.
From DSP only
Medical Savings
Account (Principal
Member)
Alliance Plus:
R7 464

Alliance Network:
R6 780
Double Plus:
R4 800

Double Network:
R4 380
-Essential Plus:
R7 380

Essential Network:
R6 660
--
Benefit Option: Alliance Plus & Alliance Network
Alliance Plus: Any Private Hospital No limits, private wards for confinements (subject to availability)
Alliance Network: Life Healthcare, Netcare No limits, private wards for confinements (subject to availability)
Attending Dr’s and Specialists: 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 (on referral from a nominated network GP or a specialist for Alliance Network)
Check-Ups and Vaccines: GP (nominated network GP referral applies for Alliance Network), Specialist, Dental, Optometry (PPN optometrist for Alliance Network), Dermatologist, ECG, Dietician
Infertility R93 300 per family
A-PLUS
A-Network

ALLIANCE PLUS & ALLIANCE NETWORK

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).
The DSP hospital groups for Alliance Network are Life Healthcare and Netcare.
20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies.

ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS, MEDICAL AND SURGICAL PROCEDURES INCLUDING CONFINEMENTS

SUBJECT TO PRE-AUTHORISATION

300% CBT
300% 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

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 R93 300 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, PROTOCOLS AND FORMULARIES

REFER TO CHRONIC DISEASE LIST

100% SEP plus a dispensing fee, subject to RP and DSP.
Consultations and procedures - as per PMB regulations (For Alliance Network - on referral from a nominated network GP)

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
(For Alliance Network - on referral from a nominated network)

ONCOLOGY

SUBJECT TO PREAUTHORISATION AND ICON Protocols#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 300% CBT
The ICON Enhanced benefits apply
(For Alliance Network, the DSP is the ICON network)

#Please refer to website for ICON benefit structures.

A-PLUS
A-Network

ALLIANCE PLUS & ALLIANCE NETWORK

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 and free Online Wellness Club.

ONE GP CONSULTATION ONLY

*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per beneficiary. (Nominated Network GP for Alliance Network)

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 R13 760 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)

100% CBT per adult beneficiary

ONE OPTOMETRIST CONSULTATION

100% Optical Assistant Rates
(PPN optometrist for Alliance Network)

IMMUNISATION AND VACCINES

(COST OF IMMUNISATION AND VACCINE ONLY)

SEP plus a dispensing fee, limited to R5 893 per beneficiary

CERVICAL CANCER VACCINE (HPV)

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

Females between 9 and 45 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.

A-PLUS
A-Network

ALLIANCE PLUS & ALLIANCE NETWORK

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 945
Breast pumps: R4 820

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 820 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.
A-PLUS
A-Network

ALLIANCE PLUS & ALLIANCE NETWORK

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
(on referral from a nominated network GP or a specialist for Alliance Network)

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
(on referral from a nominated network GP or a specialist for Alliance Network)

POST-HOSPITALISATION

CONSULTATIONS AND TREATMENT UP TO 90 DAYS

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

MEDICATION AND TREATMENT 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
(on referral from a nominated network GP for Alliance Network; penalties apply for the use of non-nominated network GP)

EXTERNAL APPLIANCES (subject to referral)

IN AND OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE
CPAP (subject to pre-authorisation; DSP and compliance over a 3-month rental period) - 3 YEAR CYCLE
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 R94 190 per beneficiary and subject to the following sub-limits:
Hearing Aids: R94 190
Wheelchairs for Quadriplegics: R94 190
Standard Wheelchairs: R56 200
Insulin Pumps: R56 200
Other external appliances: R18 650
(on referral from a nominated network GP or a specialist for Alliance Network)

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.
The cover is available to members who are not older than 80 years of age.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation
A-PLUS
A-Network

ALLIANCE PLUS & ALLIANCE NETWORK

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 R36 600
Child R22 800

GPs AND DENTISTS

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

80% CBT
Nominated Network GP for Alliance Network

SPECIALISTS

CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY
THESE PRACTITIONERS

80% CBT (on referral from a nominated network GP for Alliance Network)

ACUTE MEDICATION

INCLUDING INJECTIONS AND MATERIALS

80% SEP plus dispensing fee, subject to MMAP, co-payment from MSA
(on referral from a nominated network GP for Alliance Network)

NON-DSP VISITS TO DOCTOR’S ROOMS

One visit per beneficiary 80% CBT for Alliance Network for non-network or non-nominated GP

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL

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 (on referral from a nominated network GP or from a specialist for Alliance Network)

ADVANCED DENTISTRY

CROWNS, BRIDGES, ORTHODONTICS, DENTURES

80% CBT limited to:
M0 R18 650
M1 R27 900
M2+ R33 600

OVER THE COUNTER MEDICATION

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R4 689 per beneficiary

LASER K/EXCIMER LASER

NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN
PREVIOUS 12 MONTHS

80% CBT limited to R14 120 per beneficiary per eye

SPECTACLES AND LENSES

FROM OPTOMETRIST ONLY
ANNUAL BENEFIT, UNLESS OTHERWISE STATED

Consultation: See Preventative Wellness Benefit
Add ons R1 830
Single vision R1 830 OR
Bifocal R3 670 OR
Varifocal R5 520 AND
Frames R8 230 OR
Contact lenses R8 000
Lenses, frames etc 80% Optical Assistant Rates
PPN is the DSP for Alliance Network

Monthly Contribution Rates: Alliance Plus & Alliance Network

Alliance PlusAlliance Network
Monthly Risk ContributionAdult
Child
R6 430
R3 491
R5 832
R3 163
Monthly MSA ContributionAdult
Child
R   622
R   286
R   565
R   260
Total Monthly ContributionAdult
Child
R7 052
R3 777
R6 397
R3 423
Benefit Option: Double Plus & Double Network
Double Plus: Any Private Hospital: No limits.
Double Network: Life Healthcare, Netcare: No limits.
Attending Dr’s and Specialists: 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 (on referral from a nominated network GP or a specialist for Double Network)
Check-ups and Vaccines: GP (nominated network GP referral applies for Double Network), Specialist, Dental, Optometry (PPN optometrist for Double Network), ECG
Infertility R65 800 per family
D-PLUS
D-Network

DOUBLE PLUS & DOUBLE NETWORK

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.
The DSP hospital groups for Double Network are Life Healthcare and Netcare.
20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies.

ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS
MEDICAL AND SURGICAL PROCEDURES INCLUDING
CONFINEMENTS SUBJECT TO PRE-AUTHORISATION

300% CBT
300% 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

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 R65 800 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, PROTOCOLS AND FORMULARIES


REFER TO CHRONIC DISEASE LIST

100% SEP plus a dispensing fee, subject to RP and DSP.
Consultations and procedures - as per PMB regulations (For Double Network - on referral from a nominated network GP)

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
(For Double Network - on referral from a nominated network)

ONCOLOGY

SUBJECT TO PREAUTHORISATION AND ICON Protocols#

Medication - 100% SEP plus a dispensing fee, subject to RP and DSP.
Consultations and procedures - at 300% CBT
The ICON Core benefits apply
(For Double Network, the DSP is the ICON network)

#Please refer to website for ICON benefit structures.

D-PLUS
D-Network

DOUBLE PLUS & DOUBLE NETWORK

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 and free Online Wellness Club

ONE GP CONSULTATION ONLY

*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per beneficiary (nominated Network GP for Double Network)

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 R13 760 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)

100% CBT per adult beneficiary

ONE OPTOMETRIST CONSULTATION

100% Optical Assistant Rates
(PPN optometrist for Double Network)

IMMUNISATION AND VACCINES

(COST OF IMMUNISATION AND VACCINE ONLY)

SEP plus a dispensing fee, limited to: Adults R2 960 - Child R4 895

CERVICAL CANCER VACCINE (HPV)

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

Females between 9 and 45 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.

D-PLUS
D-Network

DOUBLE PLUS & DOUBLE NETWORK

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 895
Breast pumps: R4 820

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 R2 066 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.
D-PLUS
D-Network

DOUBLE PLUS & DOUBLE NETWORK

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
(on referral from a nominated network GP or a specialist for Double Network)

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
(on referral from a nominated network GP or a specialist for Double Network)

POST-HOSPITALISATION

CONSULTATIONS AND TREATMENT UP TO 90 DAYS

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

MEDICATION AND TREATMENT 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
(on referral from a nominated network GP for Double Network; penalties apply for the use of non-nominated network GP)

EXTERNAL APPLIANCES (subject to referral)

IN AND OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE
CPAP (subject to pre-authorisation; DSP and compliance over a 3-month rental period) - 3 YEAR CYCLE
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 R94 190 per beneficiary and subject to the following sub-limits:
Hearing Aids: R94 190
Wheelchairs for Quadriplegics: R94 190
Standard Wheelchairs: R56 200
Insulin Pumps: R56 200
Other external appliances: R18 650

(on referral from a nominated network GP or a specialist for Double Network)

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.
The cover is available to members who are not older than 80 years of age.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation
D-PLUS
D-Network

DOUBLE PLUS & DOUBLE NETWORK

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 R14 233
Child R 9 890

GPs AND DENTISTS

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

80% CBT
Nominated Network GP for Double Network

SPECIALISTS

CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY
THESE PRACTITIONERS

80% CBT (on referral from a nominated network GP for Double Network)

ACUTE MEDICATION

INCLUDING INJECTIONS AND MATERIALS

80% SEP plus dispensing fee, subject to MMAP, co-payment from MSA
(on referral from a nominated network GP for Double Network)

NON-DSP VISITS TO DOCTOR’S ROOMS

One visit per beneficiary 80% CBT for Double Network for non-network or non-nominated GP

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL

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 (on referral from a nominated network GP or a specialist for Double Network)

ADVANCED DENTISTRY

CROWNS, BRIDGES, ORTHODONTICS, DENTURES

80% CBT limited to:
M0 R13 900
M1 R20 000
M2+ R26 900

OVER THE COUNTER MEDICATION

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R2 080 per beneficiary

LASER K/EXCIMER LASER

NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN
PREVIOUS 12 MONTHS

80% CBT limited to R5 215 per beneficiary per eye

SPECTACLES AND LENSES

FROM OPTOMETRIST ONLY
ANNUAL BENEFIT, UNLESS OTHERWISE STATED

Consultation: See Preventative Wellness Benefit
Add ons R1 200
Single vision R1 200 OR
Bifocal R3 210 OR
Varifocal R4 930 AND
Frames R4 430 OR
Contact lenses R4 300
Lenses, frames etc 80% Optical Assistant Rates
PPN is the DSP for Double Network

Monthly Contribution Rates: Double Plus & Double Network

Double PlusDouble Plus
Monthly Risk ContributionAdult
Child
R4 260
R2 439
R3 888
R2 227
Monthly MSA ContributionAdult
Child
R   400
R   257
R   365
R   234
Total Monthly ContributionAdult
Child
R4 660
R2 696
R4 253
R2 461

Benefit Option: Vital Plus & Vital Network
Vital Plus: Any Private Hospital: No limits.
Vital Network: Life Healthcare, Netcare: No limits.
Attending Doctors and Specialists: 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
V-PLUS
V-Network

VITAL PLUS & VITAL NETWORK

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
The DSP hospital groups for Vital Network are Life Healthcare and Netcare.
20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies.

ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS
MEDICAL AND SURGICAL PROCEDURES INCLUDING
CONFINEMENTS SUBJECT TO PRE-AUTHORISATION

300% CBT
300% 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

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 , PROTOCOLS AND FORMULARIES


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 300% CBT
The ICON Core benefits apply
(For Vital Network, the DSP is the ICON network)

#Please refer to website for ICON benefit structures

V-PLUS
V-Network

VITAL PLUS & VITAL NETWORK

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 and free Online Wellness Club

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 R13 760 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)

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 961 per beneficiary

CERVICAL CANCER VACCINE (HPV)

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

Females between 9 and 45 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.

V-PLUS
V-Network

VITAL PLUS & VITAL NETWORK

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 890
Breast pumps: R4 820

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.
V-PLUS
V-Network

VITAL PLUS & VITAL NETWORK

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
CPAP (subject to pre-authorisation; DSP and compliance over a 3-month rental period) - 3 YEAR CYCLE
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 R43 340 per beneficiary and subject to the following sub-limits:
Hearing Aids: R37 660
Wheelchairs for Quadriplegics: R37 660
Standard Wheelchairs: R26 460
Insulin Pumps: R43 340
Other external appliances: R 9 440

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.
The cover is available to members who are not older than 80 years of age.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation

Monthly Contribution Rates: Vital Plus & Vital Network

  Vital PlusVital Network
Monthly income based on Total Cost to Company of Principal MemberTotal Monthly Contribution
R0 - R48 060Adult
Child
R2 475
R1 269
R2 304
R1 181
R48 061 – R120 150Adult
Child
R2 806
R1 432
R2 612
R1 333
R120 151+Adult
Child
R3 112
R1 594
R2 897
R1 484

Benefit Option: Essential Plus & Essential Network
Essential Plus: Any Private Hospital: No limits.
Essential Network: Life Healthcare, Netcare: No limits.
Attending Doctors and Specialists: 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
E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL NETWORK

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
The DSP hospital groups for Essential Network are Life Healthcare and Netcare.
20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies.

ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS
MEDICAL AND SURGICAL PROCEDURES INCLUDING
CONFINEMENTS SUBJECT TO PRE-AUTHORISATION

200% CBT
200% 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

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, PROTOCOLS AND FORMULARIES


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

E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL NETWORK

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 and free Online Wellness Club

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 R13 760 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)

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 961 per beneficiary

CERVICAL CANCER VACCINE (HPV)

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

Females between 9 and 45 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.

E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL NETWORK

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.
E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL NETWORK

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
CPAP (subject to pre-authorisation; DSP and compliance over a 3-month rental period) - 3 YEAR CYCLE
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.
The cover is available to members who are not older than 80 years of age.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation
E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL NETWORK

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

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 & Essential Network

  Essential PlusEssential Network
Monthly income based on Total Cost to Company of Principal MemberTotal Monthly Contribution
R0 - R120 150
Monthly Risk ContributionPrincipal
Adult
Child
R2 033
R1 607
R   944
R1 834
R1 449
R   852
Monthly MSA ContributionPrincipal
Adult
Child
R 615
R 490
R 292
R 555
R 440
R 262
Total Monthly ContributionPrincipal
Adult
Child
R2 648
R2 097
R1 236
R2 389
R1 889
R1 114
R120 151+
Monthly Risk ContributionPrincipal
Adult
Child
R2 442
R1 936
R1 133
R2 203
R1 747
R1 022
Monthly MSA ContributionPrincipal
Adult
Child
R 615
R 490
R 292
R 555
R 440
R 262
Total Monthly ContributionPrincipal
Adult
Child
R3 057
R2 426
R1 425
R2 758
R2 187
R1 284
Benefit Option: First Choice
Any Private Hospital: No limits
Attending Dr’s and Specialists: 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 R39 590 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

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 R39 590 per family

PATHOLOGY IN HOSPITAL

100% Negotiated Rate

INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION

100% of cost limited to R39 590 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, PROTOCOLS AND FORMULARIES


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 and free Online Wellness Club.

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 R13 760 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)

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 961 per beneficiary

CERVICAL CANCER VACCINE (HPV)

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

Females between 9 and 45 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 360
Breast pumps: R4 060

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 the Advanced Scans limit

ANTE-NATAL CLASSES

80% CBT subjects to sub-limit R1 090 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 630 per beneficiary
Advanced scans: 100% CBT limited to R39 590 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

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
CPAP (subject to pre-authorisation; DSP and compliance over a 3-month rental period) - 3 YEAR CYCLE
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

100% NAPPI price or 100% of cost, in hospital and 80% of cost out of hospital with an overall limit of R7 070 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.
The cover is available to members who are not older than 80 years of age.

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 430
(b) Advanced Dentistry R7 180
(c) Other R3 430
(d) Specialists R10 550

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 880
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 760 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 R782 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 R875.
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 R600 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 R875.

Monthly Contribution Rates: First Choice

Monthly income based on
Total Cost to Company of
Principal Member
 Total Monthly Contribution
R0 - R10 240Adult
Child
R1 220
R   743
R10 241 - R19 760Adult
Child
R1 937
R1 147
R19 761 - R26 490Adult
Child
R2 908
R1 691
R26 491 - R39 740Adult
Child
R3 643
R2 396
R39 741+Adult
Child
R3 984
R2 600
Benefit Option: Network Choice
Network Hospital: No limits (DSP hospital group is Netcare)
Attending Doctors: 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 R39 590 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

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 R39 590 per family

PATHOLOGY IN HOSPITAL

100% Negotiated Rate

INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION

100% of cost limited to R39 590 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, PROTOCOLS AND FORMULARIES


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 and free Online Wellness Club.

ONE GP CONSULTATION ONLY
*ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)

100% CBT per beneficiary (Nominated Network GP 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 R13 760 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)

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 961 per beneficiary

CERVICAL CANCER VACCINE (HPV)

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

Females between 9 and 45 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 360
Breast pumps: R4 060

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 the Advanced Scans limit

ANTE-NATAL CLASSES

80% CBT subjects to sub-limit R1 090 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 630 per beneficiary
Advanced scans: 100% CBT limited to R39 590 per family (on referral by a nominated network GP 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 R7 390 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
CPAP (subject to pre-authorisation; DSP and compliance over a 3-month rental period) - 3 YEAR CYCLE
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

100% NAPPI price or 100% of cost, limited to R7 070 per beneficiary and subject to a nominated network GP 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.
The cover is available to members who are not older than 80 years of age.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation

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 430
(b) Advanced Dentistry R7 180
(c) Other R3 430
(d) Specialists R10 550

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) - Nominated Network GP only

SPECIALISTS

CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY
THESE PRACTITIONERS

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

NON-DSP VISITS

TO DOCTOR’S ROOMS

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

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL

ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT

One casualty visit per family (facility fee, consumed meds and materials).
Limited to R1 477

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 880 per beneficiary on referral from a nominated network GP 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 760 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 R782 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 R875.
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 R600 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 R875.

Monthly Contribution Rates: Network Choice

Monthly income based on Total Cost to Company of Principal Member Total Monthly Contribution
R0 - R19 760Principal
Adult
1st Child
(rest are free)
R1 737
R1 453
R   755
R19 761 - R26 490Principal
Adult
1st Child
(rest are free)
R2 065
R1 648
R   928
R26 491 - R39 740Principal
Adult
Child
R2 472
R1 914
R1 232
R39 741+Principal
Adult
Child
R3 307
R2 669
R1 624
Monthly Contribution Rates
Alliance Plus
Monthly Risk Contribution
Adult     R6 430
Child     R3 491

Monthly MSA Contribution
Adult     R 622
Child     R 286

Total Monthly Contribution
Adult     R7 052
Child     R3 777




Alliance Network
Monthly Risk Contribution
Adult     R5 832
Child     R3 163

Monthly MSA Contribution
Adult     R 565
Child     R 260

Total Monthly Contribution
Adult     R6 397
Child     R3 423
Double Plus
Monthly Risk Contribution
Adult     R4 260
Child     R2 439

Monthly MSA Contribution
Adult     R 400
Child     R 257

Total Monthly Contribution
Adult     R4 660
Child     R2 696




Double Network
Monthly Risk Contribution
Adult     R3 888
Child     R2 227

Monthly MSA Contribution
Adult     R 365
Child     R 234

Total Monthly Contribution
Adult     R4 253
Child     R2 461
Vital Plus
Total monthly contribution for a monthly income ¹ of
R0 - R48 060:

Adult       R2 475
Child       R1 269

Total monthly contribution for a monthly income ¹ of
R48 061 - R120 150:

Adult       R2 806
Child       R1 432

Total monthly contribution for a monthly income ¹ of
R120 151+:

Adult       R3 112
Child       R1 594



Vital Network
Total monthly contribution for a monthly income ¹ of
R0 - R48 060:

Adult       R2 304
Child       R1 181

Total monthly contribution for a monthly income ¹ of
R48 061 - R120 150:

Adult       R2 612
Child       R1 333

Total monthly contribution for a monthly income ¹ of
R120 151+:

Adult       R2 897
Child       R1 484
Essential Plus
R0 - R120 150:

Monthly Risk Contribution
Principal     R2 033
Adult           R1 607
Child           R944

Monthly MSA Contribution
Principal     R615
Adult           R490
Child           R292

Total Monthly Contribution
Principal     R2 648
Adult           R2 097
Child           R1 236

R120 151+:

Monthly Risk Contribution
Principal     R2 442
Adult           R1 936
Child           R1 133

Monthly MSA Contribution
Principal     R615
Adult           R490
Child           R292

Total Monthly Contribution
Principal     R3 057
Adult           R2 426
Child           R1 425



Essential Network
R0 - R120 150:

Monthly Risk Contribution
Principal     R1 834
Adult           R1 449
Child           R852

Monthly MSA Contribution
Principal     R555
Adult           R440
Child           R262

Total Monthly Contribution
Principal     R2 389
Adult           R1 889
Child           R1 114

R120 151+:

Monthly Risk Contribution
Principal     R2 203
Adult           R1 747
Child           R1 022

Monthly MSA Contribution
Principal     R555
Adult           R440
Child           R262

Total Monthly Contribution
Principal     R2 758
Adult           R2 187
Child           R1 284
First Choice
Total monthly contribution for a monthly income ¹ of
R0 - R10 240:

Adult       R1 220
Child       R743

Total monthly contribution for a monthly income ¹ of
R10 241 - R19 760:

Adult       R1 937
Child       R1 147

Total monthly contribution for a monthly income ¹ of
R19 761 - R26 490:

Adult       R2 908
Child       R1 691

Total monthly contribution for a monthly income ¹ of
R26 491 - R39 740:

Adult       R3 643
Child       R2 396

Total monthly contribution for a monthly income ¹ of
R39 741+:

Adult       R3 984
Child       R2 600
Network Choice
Total monthly contribution for a monthly income ¹ of
R0 - R19 760:

Principal     R1 737
Adult           R1 453
1st Child     R755
(rest are free)

Total monthly contribution for a monthly income ¹ of
R19 761 - R26 490:

Principal     R2 065
Adult           R1 648
1st Child     R928
(rest are free)

Total monthly contribution for a monthly income ¹ of
R26 491 - R39 740:

Principal     R2 472
Adult           R1 914
Child           R1 232

Total monthly contribution for a monthly income ¹ of
R39 741+:

Principal     R3 307
Adult           R2 669
Child           R1 624

¹ Monthly income based on Total Cost to Company of Principal Member

Chronic Disease List - PMB CDL Conditions - All Options
ConditionConsultationLevel of Consultation Cover
ADDISON’S DISEASEGeneral Practitioner (GP), Physician, Paediatrician100% COST
ASTHMA*GP, Physician, Pulmonologist, Paediatrician100% COST
BIPOLAR MOOD DISORDER*Psychiatrist, Clinical Psychologist, Social Worker100% COST
BRONCHIECTASIS*GP, Physician, Pulmonologist, Physiotherapist100% COST
CARDIAC FAILUREGP, Physician, Cardiologist100% COST
CARDIOMYOPATHYGP, Physician, Cardiologist100% COST
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)*GP, Physician, Pulmonologist, Physiotherapist100% COST
CHRONIC RENAL DISEASEGP, Physician100% COST
CORONARY ARTERY DISEASEGP, Physician, Cardiologist, Dietician100% COST
CROHN’S DISEASEGP, Gastroenterologist, 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, 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, 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 Plus, Alliance Network, Double Plus, Double Network, Vital Plus and Vital Network
ConditionConsultationsLevel of Consultation Cover
ADHD (Alliance Plus & Alliance Network 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, Network Choice, Essential Plus and Essential Network)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 2022
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 2022 - 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, Netcare hospital group for Network Choice hospital admissions and Life Healthcare and Netcare hospital groups for Alliance Network, Double Network, Vital Network and Essential Network for 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 ACCOUNT (MSA)A 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 and Essential Network options
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.
NOMINATED GP Each beneficiary on a Network option needs to nominate a Network GP each year and use that GP only. An alternative nominated GP will be allowed should the primary nominated GP not be available. This is to improve care co-ordination.
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.
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 2022 – PDF DOWNLOAD

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