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Changes for 2021 benefit options
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

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

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT

80% CBT

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

Consultation: See Preventative Wellness Benefit
Add ons R1 760
Single vision R1 760 OR
Bifocal R3 520 OR
Varifocal R5 300 AND
Frames R7 900 OR
Contact lenses R7 680
Lenses, frames etc 80% Optical Assistant Rates

RATES

Monthly Risk Contribution
Adult R6 116
Child R3 325
Monthly MSA Contribution
Adult R610
Child R280
Total Monthly Contribution
Adult R6 726
Child R3 605

More
HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION

100% of Negotiated Rate in general ward and specialised units.
Private ward for confinements (subject to availability).

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

Up to 300% CBT
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 SUBJECT TO PRE-AUTHORISATION

100% CBT

ADVANCED SCANS (MRI/CT/PET) SUBJECT TO PRE-AUTHORISATION

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 R89 600 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

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 Enhanced benefits apply

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 R13 040 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 R5 565 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

ONE MELANOMA SCREENING

100% CBT per adult beneficiary

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 830
Breast pumps: R4 630

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 707 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.

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

POST-HOSPITALISATION CONSULTATIONS AND TREATMENT UP TO 90 DAYS

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

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 R90 400 per beneficiary and subject to the following sub-limits:
Hearing Aids: R90 400
Wheelchairs for Quadriplegics: R90 400
Standard Wheelchairs: R54 000
Insulin Pumps: R54 000
Other external appliances: R17 900

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

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

Annual Overall Limits
Adult R35 100
Child R21 900

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

80% CBT

SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS

80% CBT

ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS

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

NON-DSP VISITS TO DOCTOR’S ROOMS

Not applicable

NURSE VISITS

80% CBT up to 21 days

SUPPLEMENTARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMOEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY

80% CBT

ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES

80% CBT limited to:
M0 R17 900
M1 R26 800
M2+ R32 200

OVER THE COUNTER MEDICATION

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R4 500 per beneficiary

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

80% CBT limited to R13 550 per beneficiary per eye

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