Displaying details for VITAL
| VITAL | |
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| 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 | No benefit |
| 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 the website for ICON benefit structures | |
| 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 |
| 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 700 Breast pumps: R4 500 |
| METABOLIC SCREENING FOR NEW BORN BABIES | 100% Negotiated Rate per new born baby |
| ANTE-NATAL FOETAL SCANS PER PREGNANCY | No Benefit |
| ANTE-NATAL CLASSES | No Benefit |
| UMBILICAL STEM CELL HARVESTING | Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits. |
| 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 |
| OTHER BENEFITS (per Beneficiary) SUBJECT TO THE ANNUAL OVERALL DAY-TO-DAY BENEFIT LIMIT | |
| DAY TO DAY BENEFITS BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT | No Benefit |
| GP’S AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY | No Benefit |
| SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS | No Benefit |
| ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS | No Benefit |
| NON-DSP VISITS TO DOCTORS ROOMS | Not applicable |
| CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATIONS WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT | No Benefit |
| NURSE VISITS | No Benefit |
| SUPPLEMENTARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMOEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY | No Benefit |
| ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES | No Benefit |
| OVER THE COUNTER MEDICATION | No Benefit |
| LASER K/EXCIMER LASER NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS. IF THE LASER K BENEFIT IS UTILISED, NO SPECTACLE AND CONTACT LENSE BENEFIT ALLOWED FOR 2 YEARS | No Benefit |
| SPECTACLES AND LENSES FROM OPTOMETRIST ONLY ANNUAL BENEFIT, UNLESS OTHERWISE STATED | No Benefit |
| MONTHLY CONTRIBUTION RATES | |
| RATES | Monthly income based on Total Cost to Company of Principal Member Total Monthly Contribution R0 – 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 |
