CAMAF Benefit Brochure 2021

This brochure is for summary purposes only and does not supersede the rules of the Scheme in any way.

CAMAF BENEFIT OPTION 2021 – PDF DOWNLOAD

CAMAF Benefit Option Summary
Alliance Double Plus Vital Essential Plus First Choice Network Choice
Hospital and Chronic ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆
Day to Day ☆☆☆☆☆ ☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆
Preventative Wellness Benefits ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆
MSA (savings) ☆☆☆☆ ☆☆☆☆☆ ☆☆☆☆☆
Target Market Executives, mature families and members with significant health risks. Young families or couples trying to conceive. Single members or couples without children in need of major risks covered. Entry to mid-level wanting to put away savings for day-day expenses. Entry-level and support staff at member firms. Entry-level and support staff willing to make use of networks.
CAMAF Benefit Options: Quick Summary
AllianceDouble PlusVitalEssential PlusFirst ChoiceNetwork Choice
Hospital Facility FeesAny private hospital.
Private wards
Any private hospitalAny private hospitalAny private hospitalAny private hospitalNetcare hospitals only
Attending Doctor’s and Specialists in HospitalUp to 300% CBTUp to 300% CBTUp to 300% CBTUp to 200% CBTUp to 100% CBTUp to 100% CBT
Chronic condition cover: medicines and consults64 Conditions
List of conditions
Additional conditions
63 Conditions
List of conditions
Additional conditions
63 Conditions
List of conditions
Additional conditions
27 Conditions
List of conditions
27 Conditions
List of conditions
27 Conditions
List of conditions
Radiology and PathologyUnlimited In or Out of HospitalUnlimited In or Out of HospitalUnlimited In or Out of HospitalUnlimited In Hospital,
Out of Hospital from MSA
Limits apply In and Out of HospitalLimits apply In and Out of Hospital
Preventative Wellness Benefits14 extra benefits14 extra benefits14 extra benefits14 extra benefits10 extra benefits10 extra benefits
Day to Day Overall Limit (Principal Member)R35 100R13 659--R3 290 for Medicines.
R10 120 for Specialists.
R3 290 for Other.
Paid at 80%
R3 290 for Medicines.
R10 120 for Specialists.
R3 290 for Other.
From DSP only
Medical Savings
Account (Principal
Member)
R7 320R4 704-R7 080--
Benefit Option: Alliance
Any Private Hospital: No limits, private wards for confinements (subject to availability)
Attending Dr’s and Specialists: Up to 300% CBT
64 Chronic Conditions medication and consultations. Includes unlimited appropriate biological drugs and specialised technology
Unlimited X-Rays and Blood Tests IN and OUT of hospital including MRI and CT scans
Screening Benefit
3 Month post hospitalisation benefit
External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor
Check-Ups and Vaccines: GP, Specialist, Dental, Optometry, Dermatologist, ECG, Dietician
Infertility R89 600 per family
Alliance

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

IN HOSPITAL AND PRESCRIBED MINIMUM BENEFITS

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

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

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

#Please refer to website for ICON benefit structures.

Alliance

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 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

MELANOMA SCREENING

100% CBT per adult beneficiary

*Refer to website for relevant ICD 10 codes.

Alliance

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

MATERNITY BENEFITS

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.
Alliance

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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
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
Alliance

ALLIANCE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

OTHER BENEFITS (per Beneficiary)
SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT

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

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL

ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT

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

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

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

Monthly Contribution Rates: Alliance

Monthly Risk ContributionAdult
Child
R6 116
R3 325
Monthly MSA ContributionAdult
Child
R   610
R   280
Total Monthly ContributionAdult
Child
R6 726
R3 605
Benefit Option: Double Plus
Any Private Hospital: No limits
Attending Dr’s and Specialists: Up to 300% CBT
63 Chronic Conditions Medication and Consultations. Includes unlimited appropriate Biological Drugs and
Specialised Technology
Unlimited X-rays and Blood Tests In and Out of Hospital including MRI and CT Scans
Screening Benefits
3 Month Post Hospitalisation Benefit
External Appliances: wheelchair, hearing aid, breast pump, baby sleep monitor
Check-ups and Vaccines: GP, Specialist, Dental, Optometry, ECG
Infertility R63 200 per family
Double-Plus

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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
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
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

Treatment limited to R63 200 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 Core benefits apply

#Please refer to website for ICON benefit structures.

Double-Plus

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 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: Adults R2 790 - Child R4 622

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

*Refer to website for relevant ICD 10 codes.

Double-Plus

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

MATERNITY BENEFITS

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 780
Breast pumps: R4 630

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 R1 983 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.
Double-Plus

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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
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 R72 300 per beneficiary and subject to the following sub-limits:
Hearing Aids: R72 300
Wheelchairs for Quadriplegics: R72 300
Standard Wheelchairs: R46 100
Insulin Pumps: R47 200
Other external appliances: R15 500

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
Double-Plus

DOUBLE PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

OTHER BENEFITS (per Beneficiary)
SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT

DAY TO DAY BENEFITS

BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT


Annual Overall Limits
Adult R13 659
Child R 9 491

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

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL

ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT

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

ADVANCED DENTISTRY

CROWNS, BRIDGES, ORTHODONTICS, DENTURES

80% CBT limited to:
M0 R13 300
M1 R19 200
M2+ R25 800

OVER THE COUNTER MEDICATION

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R1 990 per beneficiary

LASER K/EXCIMER LASER

NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN
PREVIOUS 12 MONTHS

80% CBT limited to R5 005 per beneficiary per eye

SPECTACLES AND LENSES

FROM OPTOMETRIST ONLY
ANNUAL BENEFIT, UNLESS OTHERWISE STATED

Consultation: See Preventative Wellness Benefit
Add ons R1 150
Single vision R1 150 OR
Bifocal R3 080 OR
Varifocal R4 730 AND
Frames R4 250 OR
Contact lenses R4 130
Lenses, frames etc 80% Optical Assistant Rates

Monthly Contribution Rates: Double Plus

Monthly Risk ContributionAdult
Child
R4 050
R2 320
Monthly MSA ContributionAdult
Child
R   392
R   252
Total Monthly ContributionAdult
Child
R4 442
R2 572
Benefit Option: Vital
Any Private Hospital: No limits
Attending Doctors and Specialists: Up to 300% of CBT
63 Chronic Conditions: Medication and consultations. Covers the medication and necessary consultations and procedures. Includes unlimited appropriate biological drugs and specialised technology as well as door to door medication delivery
Unlimited X-Rays and Blood Tests IN and OUT of hospital including MRI’s and CT’s
Screening Benefits
3 Month post hospitalisation benefit
External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor
Check-Ups and Vaccines: GP, Specialist, Dental, Optometry, ECG
Vital

VITAL

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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
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
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

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 Core benefits apply

#Please refer to website for ICON benefit structures

Vital

VITAL

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 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 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

MELANOMA SCREENING

100% CBT per adult beneficiary

*Refer to website for relevant ICD 10 codes.

Vital

VITAL

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

MATERNITY BENEFITS

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 780
Breast pumps: R4 630

METABOLIC SCREENING FOR NEW BORN BABIES

100% Negotiated Rate per new born baby

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.
Vital

VITAL

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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
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 R41 600 per beneficiary and subject to the following sub-limits:
Hearing Aids: R36 150
Wheelchairs for Quadriplegics: R36 150
Standard Wheelchairs: R25 400
Insulin Pumps: R41 600
Other external appliances: R 9 060

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

Monthly Contribution Rates: Vital

Monthly income based on
Total Cost to Company of
Principal Member
Total Monthly Contribution
R0 - R46 120Adult

Child
R2 375
R1 218
R46 121 – R115 310Adult

Child
R2 693
R1 374
R115 311+Adult

Child
R2 987
R1 530
Benefit Option: Essential Plus
Any Private Hospital: No limits
Attending Doctors and Specialists: Up to 200% of CBT
27 Chronic Conditions: Medication and consultations
Unlimited X-Rays and Blood Tests IN hospital including MRI and CT scans
Screening Benefits
Check-ups and Immunisation Benefits
Essential-Plus

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 200% CBT
200% CBT

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
Exclusions: cochlear implants

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

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

#Please refer to website for ICON benefit structures

Essential-Plus

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 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 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 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

MELANOMA SCREENING

100% CBT per adult beneficiary

*Refer to website for relevant ICD 10 codes.

Essential-Plus

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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

Subject to Medical Savings Account

METABOLIC SCREENING FOR NEW BORN BABIES

100% Negotiated Rate per new born baby

ANTE-NATAL FOETAL SCANS PER PREGNANCY

Subject to Medical Savings Account

ANTE-NATAL CLASSES

Subject to Medical Savings Account

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.
Essential-Plus

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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

Subject to Medical Savings Account

PATHOLOGY

OUT OF HOSPITAL
PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY
A MEDICAL PRACTITIONER
PRE-AUTHORISATION REQUIRED FOR ADVANCED PATHOLOGY

Subject to Medical Savings Account

POST-HOSPITALISATION

CONSULTATIONS AND TREATMENT UP TO 90 DAYS

Subject to Medical Savings Account

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

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/p>

Subject 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.
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
Essential-Plus

ESSENTIAL PLUS

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

OTHER BENEFITS (per Beneficiary)
SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT

DAY TO DAY BENEFITS

BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT

Limited 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 DENTISTRY

Subject to Medical Savings Account

SPECIALISTS

CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY
THESE PRACTITIONERS

Subject to Medical Savings Account

ACUTE MEDICATION

INCLUDING INJECTIONS AND MATERIALS

Subject to Medical Savings Account

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL

ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT

Subject to Medical Savings Account

NURSE VISITS

Subject to Medical Savings Account

SUPPLEMENTARY HEALTH

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

Subject to Medical Savings Account

BENEFIT SPECIFIC LIMITS

ADVANCED DENTISTRY

CROWNS, BRIDGES, ORTHODONTICS, DENTURES

Subject to Medical Savings Account

OVER THE COUNTER MEDICATION

Subject to Medical Savings Account

LASER K/EXCIMER LASER

NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN
PREVIOUS 12 MONTHS

Subject to Medical Savings Account

SPECTACLES AND LENSES

FROM OPTOMETRIST ONLY
ANNUAL BENEFIT, UNLESS OTHERWISE STATED

Subject to Medical Savings Account

Monthly Contribution Rates: Essential Plus

Monthly income based on
Total Cost to Company of
Principal Member
Total Monthly Contribution
R0 - R115 310Principal

Adult

Child
R1 951
R1 542
R   906
Monthly MSA ContributionPrincipal

Adult

Child
R 590
R 470
R 280
Total Monthly ContributionPrincipal

Adult

Child
R2 541
R2 012
R1 186
R115 311+Principal

Adult

Child
R2 344
R1 858
R1 087
Monthly MSA ContributionPrincipal

Adult

Child
R 590
R 470
R 280
Total Monthly ContributionPrincipal

Adult

Child
R2 934
R2 328
R1 367
Benefit Option: First Choice
Any Private Hospital: No limits
Attending Dr’s and Specialists: Up to 100% CBT
27 Chronic Conditions: medication and consultations. Includes unlimited appropriate biological drugs and
specialised technology and door to door medication delivery
X-Rays and Blood Tests Advanced scans limited to R38 000 per family
Screening Benefits
80% of GP, Specialists, Dental, Optometry, Check-ups, ECG, Vaccines

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 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

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

100% CBT
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% Negotiated Rate

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

#Please refer to website for ICON benefit structures.

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 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

*Refer to website for relevant ICD 10 codes.

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 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.

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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

Basic Radiology: 100% CBT limited to R4 440 per beneficiary
Advanced scans: 100% CBT limited to R38 000 per family

PATHOLOGY

OUT OF HOSPITAL
PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER
PRE-AUTHORISATION REQUIRED FOR ADVANCED PATHOLOGY

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

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

100% NAPPI price or 100% of cost, in hospital and 80% of cost out of hospital with an overall limit of R6 790 per beneficiary

INTERNATIONAL TRAVEL COVER

PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND
SUB JECT 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

FIRST CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

OTHER BENEFITS (per Beneficiary)
SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT

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

GP's AND DENTISTS

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

80% CBT
Subject to limit (c)

SPECIALISTS

CONSULTATIONS, PROCEDURES AND RADIOLOGY
PERFORMED BY
THESE PRACTITIONERS

80% CBT
Subject to limit (d)

ACUTE MEDICATION

INCLUDING INJECTIONS AND MATERIALS

80% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a)

CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL

ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT

Medication: 80% SEP plus a dispensing fee
Subject to limit (a) Treatment: 80% CBT subject to limit (c)

NURSE VISITS

80% CBT subject to limit (c)

SUPPLEMENTARY HEALTH

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

80% CBT subject to sub-limit R2 760
Subject to limit (c)

BENEFIT SPECIFIC LIMITS

ADVANCED DENTISTRY

CROWNS, BRIDGES, ORTHODONTICS, DENTURES

50% 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)

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.

Monthly Contribution Rates: First Choice

Monthly income based on
Total Cost to Company of
Principal Member
Total Monthly Contribution
R0 - R9 830Adult

Child
R1 171
R   713
R9 831 - R18 960Adult

Child
R1 859
R1 101
R18 961 - R25 420Adult

Child
R2 791
R1 623
R25 421 - R38 140Adult

Child
R3 473
R2 284
R38 141+Adult

Child
R3 798
R2 479
Benefit Option: Network Choice
Network Hospital: No limits (DSP hospital group is Netcare)
Attending Doctors: Up to 100% CBT only at DSP
27 Chronic Conditions: medication and consultations. Includes unlimited appropriate biological drugs and
specialised technology and door to door medication delivery
X-Rays and Blood Tests Advanced scans limited to R38 000 per family
Screening Benefits
Vaccines

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

IN HOSPITAL AND PRESCRIBED MINIMUM BENEFITS

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

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

100% CBT
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

#Please refer to website for ICON benefit structures

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 (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

*Refer to website for relevant ICD 10 codes.

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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 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.

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

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

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)

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

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

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
SUB JECT 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

NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.

OTHER BENEFITS (per Beneficiary)
NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT

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

GP's 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 visit per beneficiary or two per family, 20% co-payment

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

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)

BENEFIT SPECIFIC LIMITS

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)

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 spectacl e 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.

Monthly Contribution Rates: Network Choice

Monthly income based on
Total Cost to Company of
Principal Member
Total Monthly Contribution
R0 - R18 960Principal
Adult
1st Child
(rest are free)
R1 667
R1 394
R   725
R18 961 - R25 420Principal
Adult
1st Child
(rest are free)
R1 982
R1 582
R   891
R25 421 - R38 140Principal
Adult
1st Child
R2 372
R1 837
R1 182
R38 141+Principal
Adult
1st Child
R3 153
R2 544
R1 548
Monthly Contribution Rates
AllianceDouble PlusVitalEssential PlusFirst ChoiceNetwork Choice
Monthly Risk Contribution



Adult     R6 116

Child     R3 325



Monthly MSA Contribution

Adult     R 610

Child     R 280



Total Monthly Contribution

Adult     R6 726

Child     R3 605

Monthly Risk Contribution



Adult     R4 050

Child     R2 320



Monthly MSA Contribution

Adult     R 392

Child     R 252



Total Monthly Contribution

Adult     R4 442

Child     R2 572

Monthly income based on
Total Cost to Company of
Principal Member


Total Monthly Contribution
R 0 - R46 120

Adult       R2 375

Child       R1 218



R46 121 - R115 310

Adult       R2 693

Child       R1 374



R115 311+

Adult       R2 987

Child       R1 530
Monthly income based on
Total Cost to Company of
Principal Member


Total Monthly Contribution

R 0 - R115 310

Principal     R1 951

Adult           R1 542

Child           R 906



Monthly MSA Contribution

Principal     R 590

Adult           R 470

Child           R 280



Total Monthly Contribution

Principal     R2 541

Adult           R2 012

Child           R1 186




R115 311+

Principal     R2 344

Adult           R1 858

Child           R1 087



Monthly MSA Contribution

Principal     R 590

Adult           R 470

Child           R 280



Total Monthly Contribution

Principal     R2 934

Adult           R2 328

Child           R1 367
Monthly income based on
Total Cost to Company of
Principal Member


Total Monthly Contribution

R0 - R9 830

Adult       R1 171

Child       R 713



R9 831 - R18 960

Adult       R1 859

Child       R1 101



R18 961 - R25 420

Adult       R2 791

Child       R1 623



R25 421 - R38 140

Adult       R3 473

Child       R2 284



R38 141+

Adult       R3 798

Child       R2 479
Monthly income based on
Total Cost to Company of
Principal Member


Total Monthly Contribution

R 0 - R18 960

Principal   R1 667

Adult         R1 394

1st Child   R 725

(rest are free)



R18 961- R25 420

Principal   R1 982

Adult         R1 582

1st Child   R 891

(rest are free)



R25 421 - R38 140

Principal   R2 372

Adult         R1 837

Child         R1 182



R38 141+

Principal   R3 153

Adult         R2 544

Child         R1 548
Chronic Disease List - PMB CDL Conditions - All Options
ConditionConsultationLevel of Consultation Cover
ADDISON’S DISEASEGeneral Practitioner (GP), Physician, Paediatrician100% COST
ASTHMA*GP, Physician, Pulmonologist, Paediatrician100% COST
BIPOLAR MOOD DISORDER*Psychiatrist, Clinical Psychologist, Social Worker100% COST
BRONCHIECTASIS*GP, Physician, Pulmonologist, Physiotherapist100% COST
CARDIAC FAILUREGP, Physician, Cardiologist100% COST
CARDIOMYOPATHYGP, Physician, Cardiologist100% COST
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)*GP, Physician, Pulmonologist, Physiotherapist100% COST
CHRONIC RENAL DISEASEGP, Physician100% COST
CORONARY ARTERY DISEASEGP, Physician, Cardiologist, Dietician100% COST
CROHN’S DISEASEGP, Gastroenterologist, Physician, General Surgeon100% COST
DIABETES INSIPIDUSGP, Physician, Paediatrician, Endocrinologist100% COST
DIABETES MELLITUS (TYPE 1 AND TYPE 2)*GP, Physician, Paediatrician, Ophthalmologist, Dietician, Podiatrist, Endocrinologist100% COST
DYSRHYTHMIAGP, Physician, Cardiologist, Paediatrician100% COST
EPILEPSYGP, Physician, Neurologist, Paediatrician100% COST
GLAUCOMAGP, Physician, Ophthalmologist100% COST
HAEMOPHILIA A & BGP, Physician, Paediatrician, Haematologist100% COST
HIV/AIDS**GP, Physician, Paediatrician100% COST
HYPERLIPIDAEMIA*GP, Physician, Cardiologist, Paediatrician, Dietician100% COST
HYPERTENSION*GP, Physician, Cardiologist, Dietician100% COST
HYPOTHYROIDISMGP, Physician, Paediatrician100% COST
MULTIPLE SCLEROSISGP, Physician, Neurologist, Ophthalmologist, Urologist, Occupational Therapist, Physiotherapist100% COST
PARKINSON’S DISEASEGP, Physician, Neurologist100% COST
Rheumatoid ArthritisGP, Physician, Rheumatologist, Paediatrician100% COST
SCHIZOPHRENIA*Psychiatrist, Clinical Psychologist, Social Worker100% COST
SYSTEMIC LUPUS ERYTHEMATOSISGP, Physician, Dermatologist, Paediatrician100% COST
ULCERATIVE COLITISGastroenterologist, GP, Physician100% COST

In terms of the Medical Schemes Act Regulations that came into effect on 1 January 2004, Medical Schemes are required to fund the cost of the diagnosis, medical management
(consultations and procedures) and medication of the specified list of chronic conditions. All of these conditions are covered by CAMAF.
*Subject to registration on relevant Wellness Programme.
**Subject to registration with LifeSense.

Chronic Disease List - Additional Chronic Conditions - Alliance, Double Plus and Vital options
ConditionConsultationsLevel of Consultation Cover
ADHD (Alliance Plus & Alliance Network only)Paediatrician, Neurologist, Psychiatrist100% CBT
ALLERGIC RHINITISGP, Ear Nose and Throat Specialist (ENT), Paediatrician100% CBT
ALZHEIMER’S DISEASENeurologist, Psychiatrist100% CBT
ANKYLOSING SPONDYLITISPhysician, Rheumatologist100% CBT
BENIGN PROSTATIC HYPERTROPHYUrologist100% CBT
CHRONIC GRANULOMATOUS DISEASEPhysician100% CBT
COAGULATION DISORDERSCardiologist, Physician, Clinical Haemotologist100% CBT
CONGENITAL HEART MALFORMATIONSPhysician, Cardiologist, Paediatrician100% CBT
CYSTIC FIBROSISPhysician, Physiotherapist, Pulmonologist, Paediatrician, GP100% CBT
DEEP VEIN THROMBOSISPhysician100% CBT
DEPRESSION (includes First Choice, Essential Plus and Essential Network)GP, Psychiatrist, Clinical Psychologist, Social Worker100% CBT
ECZEMADermatologist, GP100% CBT
ENDOMETRIOSISGynaecologist100% CBT
GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)GP, Gastroenterologist, Physician, Paediatrician100% CBT
GAUCHERS DISEASEPhysician, Paediatrician100% CBT
GOUT PROPHYLAXISGP100% CBT
HORMONE REPLACEMENTGP100% CBT
HYPERPARATHYROIDISMPhysician100% CBT
HYPERTHYROIDISMGP, Paediatrician100% CBT
MENIERE’S DISEASEGP, Ear Nose and Throat Specialist (ENT)100% CBT
MIGRAINE PROPHYLAXISGP, Neurologist100% CBT
MUSCULAR DYSTROPHYNeurologist, Physician, Paediatrician100% CBT
MYASTHENIA GRAVISPhysician100% CBT
NARCOLEPSYNeurologist100% CBT
ORGAN TRANSPLANTAppropriate multi disciplinary team100% CBT
OSTEOARTHRITISPhysician, Rheumatologist, GP100% CBT
OSTEOPOROSISPhysician, Gynaecologist, GP100% CBT
PLEGIA; HEMI, PARA & QUADPhysician, Orthopaedic Surgeon, Physiotherapist, Urologist, Neurologist, Occupational Therapist, Paediatrician, Speech Therapist, GP100% CBT
POLYCYSTIC OVARIAN SYNDROMEGynaecologist100% CBT
PSORIASISDermatologist100% CBT
RESTRICTIVE LUNG DISEASEPulmonologist, Physician100% CBT
TRANSIENT ISCHAEMIC ATTACK / STROKEPhysician, Neurologist100% CBT
TUBERCULOSISGP100% CBT
VALVULAR HEART DISEASEPhysician, Cardiologist, Paediatrician100% CBT
ICD10 Codes 2021
BenefitPractice TypeICD 10 CodesICD 10 Description
GP ConsultationGP (14)Z00.0General Medical Examination
Z00.1Routine Child Health Examination
Z00.8Other General Examinations
Z01.3Examination Of Blood Pressure
Z01.4Gynaecological Examination (General)(Routine)
Z10.8Routine General Health Check-Up Of Other Defined Subpopulations
Z12.4Special Screening Examination For Neoplasm Of Cervix
Z12.5Special Screening Examination For Neoplasm Of Prostate
Z13.1Special Screening Examination For Diabetes Mellitus
Z13.6Special Screening Examination For Cardiovascular Disorders
Specialist ConsultationPaediatrician (32)Z00.0General Medical Examination
Z00.1Routine Child Health Examination
Z00.8Other General Examinations
Z10.8Routine General Health Check-Up Of Other Defined Subpopulations
Specialist ConsultationGynaecologist (16)Z00.0General Medical Examination
Specialist Physician (18)Z00.8Other General Examinations
Urologist (46)Z01.3Examination Of Blood Pressure
Z01.4Gynaecological Examination (General)(Routine)
Z10.8Routine General Health Check-Up Of Other Defined Subpopulations
Z12.4Special Screening Examination For Neoplasm Of Cervix
Z12.5Special Screening Examination For Neoplasm Of Prostate
Z13.1Special Screening Examination For Diabetes Mellitus
Z13.6Special Screening Examination For Cardiovascular Disorders
Melanoma ScreeningDermatologist (12)Z12.8Special Screening Examination for Neoplasm of other sites
Z12.9Special Screening Examination for Neoplasm, unspecified
D22.0Melanocytic naevi of lip
D22.1Melanocytic naevi of eyelid, including canthus
D22.2Melanocytic naevi of ear and external auricular canal
D22.3Melanocytic naevi of other and unspecified parts of face
D22.4Melanocytic naevi of scalp and neck
D22.5Melanocytic naevi of trunk
D22.6Melanocytic naevi of upper limb, including shoulder
D22.7Melanocytic naevi of lower limb, including hip
D22.9Melanocytic naevi, unspecified
CAMAF Benefit Option 2021 - Pdf Download
Glossary

*More details available on the website www.camaf.co.za
– for full explanations, consult the Registered Rules

ADULTRefers to the member and dependants who are 22 or older at any time in the year of cover.
CBTCAMAF Base Tariff - the maximum rate paid by the Scheme to providers of healthcare services, based on 2009 RPL (Medical Aid) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options.
CDLChronic Disease List - the list of PMB’s includes 25 common chronic conditions called CDL’s. Schemes must provide cover for the diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s).
CML/ FORMULARYCondition Medicine List - once a patient’s chronic condition has been registered, a patient will have access to the CML. This is a list of drugs, appropriate for the condition, that do not require authorisation. This is maintained by the Scheme and differs per Option. Reference pricing may still apply.
CHILDRefers to a dependant who is younger than an adult, as defined above.
DISPENSING FEESFee negotiated by the Scheme with Network pharmacies and added to SEP.
DSPThe network of service providers contracted to provide healthcare services to members, eg. Independent Clinical Oncology Network (ICON), HIV programme (LifeSense), PPN for optical benefits, Pharmacy networks for all chronic medications, Netcare 911 for emergency transport and Netcare hospital group for Network Choice hospital admissions.
DTPThe Regulations to the Medical Schemes Act in Annexure A provide a list of conditions identified as Prescribed Minimum Benefits. The List is in the form of Diagnosis Treatment Pairs (DTP’s). A DTP links a specific diagnosis to a treatment/procedure and therefore broadly indicates how each of the 270 PMB conditions should be treated. These treatment pairs cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s).
ICD 10 CODEStands for International Classification of Diseases and Related Health Problems (10th revision). It is a coding system developed by the World Health Organisation (WHO) that translates the written description of medical and health information into standard codes, e.g. J03.9 is an ICD-10 code for acute tonsillitis (unspecified) and G40.9 denotes epilepsy (unspecified). These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be paid from the correct benefit.
INCOMETotal cost to company prior to deductions.
MEDICAL SAVINGS ACCOUNT (MSA)A savings account that accrues monthly but the annualised amount of savings is available immediately and can be used for:
• top up on cost of service charged by a doctor
• extension when an overall benefit has been exceeded
• exclusion from benefits
• payment of day to day claims on Essential Plus option
METABOLIC SCREENINGNewborn screening whereby rare disorders are detected by a blood test done 48 - 72 hours after birth.
MMAPMaximum Medical Aid Price - is a reference price model and determines the maximum medical scheme price that medical schemes will reimburse for an interchangeable multi-source pharmaceutical product (generic) on the relevant option. MMAP applies to all options for chronic medication.
NEGOTIATED RATEThis is the rate, negotiated by the scheme with the service provider/group of service providers, eg. hospitals and pathologists.
PMBPrescribed Minimum Benefits - as set out in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the diagnosis, treatment and care of:
• Any emergency medical condition
• A limited set of 270 medical conditions (Defined in DTP’s)
• 25 chronic conditions defined in the CDL
• These costs may not be paid from the member’s savings benefit and cost saving measures can be used by way of utilising DSP’s, Reference Pricing and Formularies.
PRE-AUTHORISATIONA member must obtain prior approval for an intended admission to hospital. Failure to pre-authorise could result in wholly or partly disallowing the claim or imposing a penalty of 20% of related accounts up to a maximum of R 2 500. Emergency treatment is not subject to Pre-authorisation but members should notify the Scheme as soon as possible after the event.
PROTOCOLMeans a set of guidelines in relation to diagnostic testing and management of specific conditions and includes, but is not limited to, clinical practice guidelines, standard treatment guidelines and disease management guidelines.
RISK CONTRIBUTIONSThose funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account.
RPReference Pricing is the maximum price for which the Scheme will be liable for specific medicine or classes of medicine, listed on the Scheme’s Condition Medicine List (CML). The reference price varies per option and where a drug is above the reference price it is indicated that a co-payment will apply. This includes MMAP.
SEPSingle Exit Price - nationally applied pricing for medication as determined by the Department of Health and the pharmaceutical manufacturers.
TTO“To Take Out” - medication supplied by the hospital for use after the date of discharge from hospital - limited to a 7 day supply.

CAMAF BENEFIT OPTION 2021 – PDF DOWNLOAD