| HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | 100% of Negotiated Rate in general ward and specialised units., The DSP hospital groups 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 |
| 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 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 (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 (on referral from a nominated network GP) |
| 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 |
| 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) |
| 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 UND | 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 | PPN Rates |
| 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) | Females between 9 and 45 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. SUBJEC | 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. |
| 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) |
| PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER | 100% Negotiated Rate or CBT (on referral from a nominated network GP or a specialist) |
| 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; 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, HE | 100% NAPPI price or 100% of cost, subject to the overall limit of R75 300 per beneficiary and subject to the following sub-limits:, Hearing Aids: R75 300, Wheelchairs for Quadriplegics: R75 300, Standard Wheelchairs: R48 030, Insulin Pumps: R49 180, Other external appliances: R16 150, (on referral from a nominated network GP or a specialist) |
| 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. | R5 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 R250,000 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 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 |
| SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS | 80% CBT (on referral from a nominated network GP) |
| 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) |
| NON-DSP VISITS TO DOCTOR’S ROOMS | One visit per beneficiary 80% CBT 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) |
| 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; WHERE PPN IS INDICATED AS THE DSP, THE PPN RATES AND TARIFFS WILL APPLY. FOR ALL OTHER OPTIONS, OPTICAL ASSISTANT | 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% PPN Rates |
| RATES | Monthly Risk Contribution, Adult R3 888, Child R2 227, Monthly MSA Contribution, Adult R365, Child R234, Total Monthly Contribution, Adult R4 253, Child R2 461 |
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