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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

Referred by DSP or specialist, 100% Negotiated Rate, limited to R7 090 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

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 R 1 417

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 R750 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 R840.
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 R300 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 R840.

RATES

Income Category R0 – R18 960
Principal R1 667
Adult R1 394
1st Child (rest are free) R725
Income Category R18 961 – R25 420
Principal R1 982
Adult R1 582
1st Child (rest are free) R891
Income Category R25 421 – R38 140
Principal R2 372
Adult R1 837
Child R1 182
Income Category R38 141+
Principal R3 153
Adult R2 544
Child R1 548
Monthly income based on Total Cost to Company of Principal Member

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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

Up to 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 SUBJECT TO PRE-AUTHORISATION

100% CBT

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

100% CBT limited to R38 000 per family

PATHOLOGY IN HOSPITAL

100% CBT

INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION

100% of cost limited to R38 000 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

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 (Network Doctor 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 040 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 852 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

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 265
Breast pumps: R3 900

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 limit (c) of Annual Overall Day-to-Day Benefit Limit

ANTE-NATAL CLASSES

80% CBT subjects to sub-limit R1 050 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.

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 440 per beneficiary
Advanced scans: 100% CBT limited to R38 000 per family (on referral by DSP or specialist)

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, limited to R6 790 per beneficiary and subject to DSP or Specialist referral

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 limit: Beneficiary specific limits:
(a) Medicines R3 290
(b) Advanced Dentistry R6 890
(c) Other R3 290
(d) Specialists R10 120

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

100% negotiated rate
subject to sublimit (c) – Network GP only

SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS

100% CBT
Subject to limit (d) (on referral from a 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 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

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 760 per beneficiary on referral from DSP or from a Specialist.
Subject to limit (c)

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 690 per beneficiary.
Subject to limit (a)

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