Displaying details for ESSENTIAL PLUS



 ESSENTIAL PLUS
IN HOSPITAL AND PRESCRIBED MINIMUM BENEFITS 
HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION100% of Negotiated Rate in general ward and specialised units
ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS MEDICAL AND SURGICAL PROCEDURES INCLUDING CONFINEMENTS SUBJECT TO PRE-AUTHORISATIONUp to 200% CBT
100% of Scheme Rate
SUPPLEMENTARY HEALTHCARE IN HOSPITAL (EG. PHYSIOTHERAPY AND PSYCHOTHERAPY)100% CBT
BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL)100% of cost
RADIOLOGY IN HOSPITAL ADVANCED SCANS (MRI/CT/PET) SUBJECT TO PRE-AUTHORISATION100% CBT
100% CBT
PATHOLOGY IN HOSPITAL100% Negotiated Rate
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION100% of cost
Exclusions: cochlear implants
HOME NURSING UP TO 21 DAYS, SUBJECT TO PRE-AUTHORISATION100% CBT
STEP-DOWN/PHYSICAL REHABILITATION APPROVED FACILITIES ONLY, UP TO 90 DAYS (SUBJECT TO PRE-AUTHORISATION)100% Negotiated Rate
MEDICATION IN HOSPITAL100% SEP plus dispensing fee
TTO MEDICATION UP TO ONE WEEK’S SUPPLY100% SEP plus dispensing fee
INFERTILITY TREATMENTNo benefit
SUBSTANCE ABUSEPMB 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 LIST100% 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-AUTHORISATIONMedication – 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 the website for ICON benefit structures
PREVENTATIVE WELLNESS COVER 
CAMAF PREVENTATIVE PROGRAMME PER ADULT BENEFICIARYINCLUDES: 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 YEARS100% CBT per beneficiary
PSYCHOTHERAPY100% CBT limited to R12 300 per beneficiary
ONE DIETICIAN CONSULTATION100% CBT per beneficiary
ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY100% CBT per beneficiary
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL (CHECK UP ONLY)100% CBT per beneficiary
ONE OPTOMETRIST CONSULTATION100% 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 TEST100% CBT per beneficiary
MELANOMA SCREENING100% CBT per adult beneficiary
MATERNITY BENEFITS 
HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATIONSee 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-PROGRAMMESubject to Medical Savings Account
METABOLIC SCREENING FOR NEW BORN BABIES100% Negotiated Rate per new born baby
ANTE-NATAL FOETAL SCANS PER PREGNANCYSubject to Medical Savings Account
ANTE-NATAL CLASSESSubject to Medical Savings Account
UMBILICAL STEM CELL HARVESTINGNegotiated 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-AUTHORISATIONSubject to Medical Savings Account
PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER PRE-AUTHORISATION REQUIRED FOR ADVANCED PATHOLOGYSubject to Medical Savings Account
POST-HOSPITALISATION CONSULTATIONS AND TREATMENT UP TO 90 DAYSSubject to Medical Savings Account
MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS (SUBJECT TO PRE-AUTHORISATION) REFER TO ADDITIONAL CHRONIC CONDITIONS LISTDepression only. 100% SEP plus a dispensing fee subject to RP and DSP
Consultations 100% CBT
EXTERNAL APPLIANCES (subject to referral) IN AND OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE HEARING AIDS (subject to pre-authorisation) – 1 CLAIM PER 3 YEAR CYCLE FOR OVER 16 YEARS OF AGE YOUNGER THAN 16 YEARS OF AGE – 18 MONTH CYCLE WHEELCHAIRS – 3 YEAR CYCLE INSULIN PUMPS (rent to own over 12 months), SUBJECT TO PRE-AUTHORISATION AND DSP – 4 YEAR CYCLESubject to Medical Savings Account
INTERNATIONAL TRAVEL COVER – PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND SUBJECT TO THEIR POLICY REQUIREMENTS. ARRANGE COVER PRIOR TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS.R10 million per beneficiary per journey for emergency medical costs while you travel outside
South Africa. This cover is for a period of 90 days from your departure from South Africa. Cover for
pre-existing conditions is limited to R150,000 unless additional cover is arranged.
NETCARE 911 EMERGENCY SERVICESUnlimited
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 LIMITLimited 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 DENTISTRYSubject to Medical Savings Account
SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERSSubject to Medical Savings Account
ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALSSubject to Medical Savings Account
NON-DSP VISITS TO DOCTORS ROOMSNot applicable
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATIONS WILL BE PAID OUT OF ACUTE MEDICATION BENEFITSubject to Medical Savings Account
NURSE VISITSSubject to Medical Savings Account
SUPPLEMENTARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMOEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPYSubject to Medical Savings Account
ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURESSubject to Medical Savings Account
OVER THE COUNTER MEDICATIONSubject to Medical Savings Account
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 YEARSSubject to Medical Savings Account
SPECTACLES AND LENSES FROM OPTOMETRIST ONLY ANNUAL BENEFIT, UNLESS OTHERWISE STATEDSubject to Medical Savings Account
MONTHLY CONTRIBUTION RATES 
RATESMonthly income based on
Total Cost to Company of
Principal Member
R0 – R111 300
Principal R1 885
Adult R1 490
Child R 875
Monthly MSA Contribution
Principal R 570
Adult R 455
Child R 270
Total Monthly Contribution
Principal R2 455
Adult R1 945
Child R1 145
R111 301+
Principal R2 265
Adult R1 795
Child R1 050
Monthly Msa Contribution
Principal R 570
Adult R 455
Child R 270
Total Monthly Contribution
Principal R2 835
Adult R2 250
Child R1 320


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