CAMAF Benefit Brochure 2022

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

CAMAF BENEFIT OPTION 2022 – PDF DOWNLOAD

CAMAF Benefit Option Summary

CAMAF Benefit Options: Quick Summary


Hospital Facility Fees	Alliance Plus Any private hospital. Private wards. Alliance Network Life Healthcare, Netcare. Private wards.	Double Plus Any private hospital. Double Network Life Healthcare, Netcare.	Vital Plus Any private hospital. Vital Network Life Healthcare, Netcare.	Essential Plus Any private hospital. Essential Network Life Healthcare, Netcare.	Any private hospital	Netcare hospitals only
Attending Doctor’s and Specialists in Hospital	300% CBT	300% CBT	300% CBT	200% CBT	100% CBT	100% CBT
Chronic condition cover: medicines and consults	64 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 Pathology	Unlimited In or Out of Hospital	Unlimited In or Out of Hospital	Unlimited In or Out of Hospital	Unlimited In Hospital, Out of Hospital from MSA	Limits apply In and Out of Hospital	Limits apply In and Out of Hospital
Preventative Wellness Benefits	14 extra benefits	14 extra benefits	14 extra benefits	14 extra benefits	10 extra benefits	10 extra benefits
Day to Day Overall Limit (Principal Member)	R36 600	R14 233	-	-	R3 430 for Medicines. R10 550 for Specialists. R3 430 for Other. Paid at 80%	R3 430 for Medicines. R10 550 for Specialists. R3 430 for Other. From DSP only
Medical Savings Account (Principal Member)	Alliance Plus: R7 464 Alliance Network: R6 780	Double Plus: R4 800 Double Network: R4 380	-	Essential Plus: R7 380 Essential Network: R6 660	-	-

Benefit Option: Alliance Plus & Alliance Network

	Alliance Plus: Any Private Hospital No limits, private wards for confinements (subject to availability) Alliance Network: Life Healthcare, Netcare No limits, private wards for confinements (subject to availability)
	Attending Dr’s and Specialists: 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 (on referral from a nominated network GP or a specialist for Alliance Network)
	Check-Ups and Vaccines: GP (nominated network GP referral applies for Alliance Network), Specialist, Dental, Optometry (PPN optometrist for Alliance Network), Dermatologist, ECG, Dietician
	Infertility R93 300 per family

ALLIANCE PLUS & ALLIANCE NETWORK

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). The DSP hospital groups for Alliance Network 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 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 R93 300 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 (For Alliance Network - 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 (For Alliance Network - 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 Enhanced benefits apply (For Alliance Network, the DSP is the ICON network)

#Please refer to website for ICON benefit structures.

ALLIANCE PLUS & ALLIANCE NETWORK

PREVENTATIVE WELLNESS COVER
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 for Alliance Network)
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 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	100% Optical Assistant Rates (PPN is the DSP for Alliance Network)
IMMUNISATION AND VACCINES (COST OF IMMUNISATION AND VACCINE ONLY)	SEP plus a dispensing fee, limited to R5 893 per beneficiary
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

*Refer to website for relevant ICD 10 codes.

ALLIANCE PLUS & ALLIANCE NETWORK

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 945 Breast pumps: R4 820
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 820 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 PLUS & ALLIANCE NETWORK

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 (on referral from a nominated network GP or a specialist for Alliance Network)
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 for Alliance Network)
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 for Alliance Network; 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 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 R94 190 per beneficiary and subject to the following sub-limits: Hearing Aids: R94 190 Wheelchairs for Quadriplegics: R94 190 Standard Wheelchairs: R56 200 Insulin Pumps: R56 200 Other external appliances: R18 650 (on referral from a nominated network GP or a specialist for Alliance Network)
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 unforeseen and unexpected medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa until your return. Cover for pre-existing medical conditions for members who have not yet turned 70 years of age 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

ALLIANCE PLUS & ALLIANCE NETWORK

OTHER BENEFITS (per Beneficiary)
DAY TO DAY BENEFITS BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT	Annual Overall Limits Adult R36 600 Child R22 800
GPs AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY	80% CBT Nominated Network GP for Alliance Network
SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS	80% CBT (on referral from a nominated network GP for Alliance Network)
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 for Alliance Network)
NON-DSP VISITS TO DOCTOR’S ROOMS	One visit per beneficiary 80% CBT for Alliance Network 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 for Alliance Network)

ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES	80% CBT limited to: M0 R18 650 M1 R27 900 M2+ R33 600
OVER THE COUNTER MEDICATION	80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R4 689 per beneficiary
LASER K/EXCIMER LASER NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS	80% CBT limited to R14 120 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 RATES WILL APPLY	Consultation: See Preventative Wellness Benefit Add ons R1 830 Single vision R1 830 OR Bifocal R3 670 OR Varifocal R5 520 AND Frames R8 230 OR Contact lenses R8 000 Lenses, frames etc 80% Optical Assistant Rates PPN is the DSP for Alliance Network

Monthly Contribution Rates: Alliance Plus & Alliance Network


Monthly Risk Contribution	Adult Child	R6 430 R3 491	R5 832 R3 163
Monthly MSA Contribution	Adult Child	R 622 R 286	R 565 R 260
Total Monthly Contribution	Adult Child	R7 052 R3 777	R6 397 R3 423

Benefit Option: Double Plus & Double Network

	Double Plus: Any Private Hospital: No limits. Double Network: Life Healthcare, Netcare: No limits.
	Attending Dr’s and Specialists: 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 (on referral from a nominated network GP or a specialist for Double Network)
	Check-ups and Vaccines: GP (nominated network GP referral applies for Double Network), Specialist, Dental, Optometry (PPN optometrist for Double Network), ECG
	Infertility R65 800 per family

DOUBLE PLUS & DOUBLE NETWORK

IN HOSPITAL AND PRESCRIBED MINIMUM BENEFITS
HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION	100% of Negotiated Rate in general ward and specialised units. The DSP hospital groups for Double Network 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 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 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 (For Double Network - 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 (For Double Network - 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 (For Double Network, the DSP is the ICON network)

#Please refer to website for ICON benefit structures.

DOUBLE PLUS & DOUBLE NETWORK

PREVENTATIVE WELLNESS COVER
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 for Double Network)
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 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	100% Optical Assistant Rates (PPN optometrist for Double Network)
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

*Refer to website for relevant ICD 10 codes.

DOUBLE PLUS & DOUBLE NETWORK

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 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.

DOUBLE PLUS & DOUBLE NETWORK

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 (on referral from a nominated network GP or a specialist for Double Network)
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 for Double Network)
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 for Double Network; 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 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 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 for Double Network)
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 unforeseen and unexpected medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa until your return. Cover for pre-existing medical conditions for members who have not yet turned 70 years of age 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

DOUBLE PLUS & DOUBLE NETWORK

OTHER BENEFITS (per Beneficiary)
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 for Double Network
SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS	80% CBT (on referral from a nominated network GP for Double Network)
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 for Double Network)
NON-DSP VISITS TO DOCTOR’S ROOMS	One visit per beneficiary 80% CBT for Double Network 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 a specialist for Double Network)

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 RATES WILL APPLY	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% Optical Assistant Rates PPN is the DSP for Double Network

Monthly Contribution Rates: Double Plus & Double Network


Monthly Risk Contribution	Adult Child	R4 260 R2 439	R3 888 R2 227
Monthly MSA Contribution	Adult Child	R 400 R 257	R 365 R 234
Total Monthly Contribution	Adult Child	R4 660 R2 696	R4 253 R2 461

Benefit Option: Vital Plus & Vital Network

	Vital Plus: Any Private Hospital: No limits. Vital Network: Life Healthcare, Netcare: No limits.
	Attending Doctors and Specialists: 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 PLUS & VITAL NETWORK

IN HOSPITAL AND PRESCRIBED MINIMUM BENEFITS
HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION	100% of Negotiated Rate in general ward and specialised units The DSP hospital groups for Vital Network 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 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 (For Vital Network, the DSP is the ICON network)

#Please refer to website for ICON benefit structures

VITAL PLUS & VITAL NETWORK

PREVENTATIVE WELLNESS COVER
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
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 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	100% Optical Assistant Rates
IMMUNISATION AND VACCINES (COST OF IMMUNISATION AND VACCINE ONLY)	SEP plus a dispensing fee, limited to R1 961 per beneficiary
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

*Refer to website for relevant ICD 10 codes.

VITAL PLUS & VITAL NETWORK

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 890 Breast pumps: R4 820
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 PLUS & VITAL NETWORK

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	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 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
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 R43 340 per beneficiary and subject to the following sub-limits: Hearing Aids: R37 660 Wheelchairs for Quadriplegics: R37 660 Standard Wheelchairs: R26 460 Insulin Pumps: R43 340 Other external appliances: R 9 440
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 unforeseen and unexpected medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa until your return. Cover for pre-existing medical conditions for members who have not yet turned 70 years of age 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

VITAL PLUS & VITAL NETWORK

OTHER BENEFITS (per Beneficiary)
DAY TO DAY BENEFITS BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT	No Benefit
GP's AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY	No Benefit
SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS	No Benefit
ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS	No Benefit
NON-DSP VISITSTO DOCTOR’S ROOMS	Not applicable
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL	No Benefit
NURSE VISITS	No Benefit
SUPPLEMENTARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMOEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY	No Benefit
BENEFIT SPECIFIC LIMITS
ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES	No Benefit
OVER THE COUNTER MEDICATION	No Benefit
LASER K/EXCIMER LASER NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS	No Benefit
SPECTACLES AND LENSES FROM OPTOMETRIST ONLY ANNUAL BENEFIT, UNLESS OTHERWISE STATED	Consultation: Part of Preventative Wellness

Monthly Contribution Rates: Vital Plus & Vital Network


Monthly income based on Total Cost to Company of Principal Member		Total Monthly Contribution
R0 - R48 060	Adult Child	R2 475 R1 269	R2 304 R1 181
R48 061 – R120 150	Adult Child	R2 806 R1 432	R2 612 R1 333
R120 151+	Adult Child	R3 112 R1 594	R2 897 R1 484

Benefit Option: Essential Plus & Essential Network

	Essential Plus: Any Private Hospital: No limits. Essential Network: Life Healthcare, Netcare: No limits.
	Attending Doctors and Specialists: 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 NETWORK

IN HOSPITAL AND PRESCRIBED MINIMUM BENEFITS
HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION	100% of Negotiated Rate in general ward and specialised units The DSP hospital groups for Essential Network 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	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 FORMULARIESREFER 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 NETWORK

PREVENTATIVE WELLNESS COVER
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
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 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	100% Optical Assistant Rates
IMMUNISATION AND VACCINES (COST OF IMMUNISATION AND VACCINE ONLY)	SEP plus a dispensing fee, limited to R1 961 per beneficiary
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

*Refer to website for relevant ICD 10 codes.

ESSENTIAL PLUS & ESSENTIAL NETWORK

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 NETWORK

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	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	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.	R5 million per beneficiary per journey for emergency unforeseen and unexpected medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa until your return. Cover for pre-existing medical conditions for members who have not yet turned 70 years of age 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

ESSENTIAL PLUS & ESSENTIAL NETWORK

OTHER BENEFITS (per Beneficiary)
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	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 & Essential Network


Monthly income based on Total Cost to Company of Principal Member		Total Monthly Contribution
R0 - R120 150
Monthly Risk Contribution	Principal Adult Child	R2 033 R1 607 R 944	R1 834 R1 449 R 852
Monthly MSA Contribution	Principal Adult Child	R 615 R 490 R 292	R 555 R 440 R 262
Total Monthly Contribution	Principal Adult Child	R2 648 R2 097 R1 236	R2 389 R1 889 R1 114
R120 151+
Monthly Risk Contribution	Principal Adult Child	R2 442 R1 936 R1 133	R2 203 R1 747 R1 022
Monthly MSA Contribution	Principal Adult Child	R 615 R 490 R 292	R 555 R 440 R 262
Total Monthly Contribution	Principal Adult Child	R3 057 R2 426 R1 425	R2 758 R2 187 R1 284

Benefit Option: First Choice

	Any Private Hospital: No limits
	Attending Dr’s and Specialists: 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 R39 590 per family
	Screening Benefits
	80% of GP, Specialists, Dental, Optometry, Check-ups, ECG, Vaccines

FIRST CHOICE

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	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 R39 590 per family
PATHOLOGY IN HOSPITAL	100% Negotiated Rate
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION	100% of cost limited to R39 590 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

PREVENTATIVE WELLNESS COVER
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
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 760 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 961 per beneficiary
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

*Refer to website for relevant ICD 10 codes.

FIRST CHOICE

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 360 Breast pumps: R4 060
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 the Advanced Scans limit
ANTE-NATAL CLASSES	80% CBT subjects to sub-limit R1 090 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

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 630 per beneficiary Advanced scans: 100% CBT limited to R39 590 per family
PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER	100% Negotiated Rate limited to R7 390 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 R7 070 per beneficiary
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 unforeseen and unexpected medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa until your return. Cover for pre-existing medical conditions for members who have not yet turned 70 years of age 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

FIRST CHOICE

OTHER BENEFITS (per Beneficiary)
DAY TO DAY BENEFITS BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT	Annual overall limit: Beneficiary specific limits: (a) Medicines R3 430 (b) Advanced Dentistry R7 180 (c) Other R3 430 (d) Specialists R10 550
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 880 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 760 per beneficiary. Subject to limit (a)
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 RATES WILL APPLY	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 R782 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 R875. 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 R600 AND EITHER SPECTACLES - A frame benefit of R782 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 R210 per lens or one pair of clear flat top bifocal spectacle lenses limited to R445 per lens or one pair of clear flat top Multifocal lenses limited to R770 per lens OR CONTACT LENSES - Contact Lenses to the value of R875.

Monthly Contribution Rates: First Choice

Monthly income based on Total Cost to Company of Principal Member		Total Monthly Contribution
R0 - R10 240	Adult Child	R1 220 R 743
R10 241 - R19 760	Adult Child	R1 937 R1 147
R19 761 - R26 490	Adult Child	R2 908 R1 691
R26 491 - R39 740	Adult Child	R3 643 R2 396
R39 741+	Adult Child	R3 984 R2 600

Benefit Option: Network Choice

	Network Hospital: No limits (DSP hospital group is Netcare)
	Attending Doctors: 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 R39 590 per family
	Screening Benefits
	Vaccines

NETWORK CHOICE

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	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 R39 590 per family
PATHOLOGY IN HOSPITAL	100% Negotiated Rate
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION	100% of cost limited to R39 590 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

PREVENTATIVE WELLNESS COVER
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 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 760 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 961 per beneficiary
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

*Refer to website for relevant ICD 10 codes.

NETWORK CHOICE

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 360 Breast pumps: R4 060
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 the Advanced Scans limit
ANTE-NATAL CLASSES	80% CBT subjects to sub-limit R1 090 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

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 630 per beneficiary Advanced scans: 100% CBT limited to R39 590 per family (on referral by a nominated network GP or specialist)
PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER	Referred by DSP or specialist, 100% Negotiated Rate, limited to R7 390 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 R7 070 per beneficiary and subject to a nominated network GP 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.	R5 million per beneficiary per journey for emergency unforeseen and unexpected medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa until your return. Cover for pre-existing medical conditions for members who have not yet turned 70 years of age 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

NETWORK CHOICE

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 430 (b) Advanced Dentistry R7 180 (c) Other R3 430 (d) Specialists R10 550
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) - Nominated Network GP only
SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS	100% CBT Subject to limit (d) (on referral from a nominated 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 nominated 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
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 R1 477
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 880 per beneficiary on referral from a nominated network GP 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 760 per beneficiary. Subject to limit (a)
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 RATES WILL APPLY	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 R782 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 R875. 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 R600 AND EITHER SPECTACLES - A frame benefit of R782 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 R210 per lens or one pair of clear flat top bifocal spectacle lenses limited to R445 per lens or one pair of clear flat top Multifocal lenses limited to R770 per lens OR CONTACT LENSES - Contact Lenses to the value of R875.

Monthly Contribution Rates: Network Choice

Monthly income based on Total Cost to Company of Principal Member		Total Monthly Contribution
R0 - R19 760	Principal Adult 1st Child (rest are free)	R1 737 R1 453 R 755
R19 761 - R26 490	Principal Adult 1st Child (rest are free)	R2 065 R1 648 R 928
R26 491 - R39 740	Principal Adult Child	R2 472 R1 914 R1 232
R39 741+	Principal Adult Child	R3 307 R2 669 R1 624

Monthly Contribution Rates

Monthly Risk Contribution
Adult R6 430
Child R3 491

Monthly MSA Contribution
Adult R 622
Child R 286

Total Monthly Contribution
Adult R7 052
Child R3 777

Monthly Risk Contribution
Adult R5 832
Child R3 163

Monthly MSA Contribution
Adult R 565
Child R 260

Total Monthly Contribution
Adult R6 397
Child R3 423

Monthly Risk Contribution
Adult R4 260
Child R2 439

Monthly MSA Contribution
Adult R 400
Child R 257

Total Monthly Contribution
Adult R4 660
Child R2 696

Monthly Risk Contribution
Adult R3 888
Child R2 227

Monthly MSA Contribution
Adult R 365
Child R 234

Total Monthly Contribution
Adult R4 253
Child R2 461

Total monthly contribution for a monthly income ¹ of
R0 - R48 060
Adult R2 475
Child R1 269

Total monthly contribution for a monthly income ¹ of
R48 061 - R120 150
Adult R2 806
Child R1 432

Total monthly contribution for a monthly income ¹ of
R120 151+
Adult R3 112
Child R1 594

Total monthly contribution for a monthly income ¹ of
R0 - R48 060
Adult R2 304
Child R1 181

Total monthly contribution for a monthly income ¹ of
R48 061 - R120 150
Adult R2 612
Child R1 333

Total monthly contribution for a monthly income ¹ of
R120 151+
Adult R2 897
Child R1 484

R0 - R120 150 ¹

Monthly Risk Contribution
Principal R2 033
Adult R1 607
Child R944

Monthly MSA Contribution
Principal R615
Adult R490
Child R292

Total Monthly Contribution
Principal R2 648
Adult R2 097
Child R1 236

R120 151+ ¹

Monthly Risk Contribution
Principal R2 442
Adult R1 936
Child R1 133

Monthly MSA Contribution
Principal R615
Adult R490
Child R292

Total Monthly Contribution
Principal R3 057
Adult R2 426
Child R1 425

R0 - R120 150 ¹

Monthly Risk Contribution
Principal R1 834
Adult R1 449
Child R852

Monthly MSA Contribution
Principal R555
Adult R440
Child R262

Total Monthly Contribution
Principal R2 389
Adult R1 889
Child R1 114

R120 151+ ¹

Monthly Risk Contribution
Principal R2 203
Adult R1 747
Child R1 022

Monthly MSA Contribution
Principal R555
Adult R440
Child R262

Total Monthly Contribution
Principal R2 758
Adult R2 187
Child R1 284

Total monthly contribution for a monthly income ¹ of
R0 - R10 240
Adult R1 220
Child R743

Total monthly contribution for a monthly income ¹ of
R10 241 - R19 760
Adult R1 937
Child R1 147

Total monthly contribution for a monthly income ¹ of
R19 761 - R26 490
Adult R2 908
Child R1 691

Total monthly contribution for a monthly income ¹ of
R26 491 - R39 740
Adult R3 643
Child R2 396

Total monthly contribution for a monthly income ¹ of
R39 741+
Adult R3 984
Child R2 600

Total monthly contribution for a monthly income ¹ of
R0 - R19 760
Principal R1 737
Adult R1 453
1st Child R755
(rest are free)

Total monthly contribution for a monthly income ¹ of
R19 761 - R26 490
Principal R2 065
Adult R1 648
1st Child R928
(rest are free)

Total monthly contribution for a monthly income ¹ of
R26 491 - R39 740
Principal R2 472
Adult R1 914
Child R1 232

Total monthly contribution for a monthly income ¹ of
R39 741+
Principal R3 307
Adult R2 669
Child R1 624

¹ Monthly income based on Total Cost to Company of Principal Member

Chronic Disease List - PMB CDL Conditions - All Options

Condition	Consultation	Level of Consultation Cover
ADDISON’S DISEASE	General Practitioner (GP), Physician, Paediatrician	100% COST
ASTHMA*	GP, Physician, Pulmonologist, Paediatrician	100% COST
BIPOLAR MOOD DISORDER*	Psychiatrist, Clinical Psychologist, Social Worker	100% COST
BRONCHIECTASIS*	GP, Physician, Pulmonologist, Physiotherapist	100% COST
CARDIAC FAILURE	GP, Physician, Cardiologist	100% COST
CARDIOMYOPATHY	GP, Physician, Cardiologist	100% COST
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)*	GP, Physician, Pulmonologist, Physiotherapist	100% COST
CHRONIC RENAL DISEASE	GP, Physician	100% COST
CORONARY ARTERY DISEASE	GP, Physician, Cardiologist, Dietician	100% COST
CROHN’S DISEASE	GP, Gastroenterologist, Physician, General Surgeon	100% COST
DIABETES INSIPIDUS	GP, Physician, Paediatrician, Endocrinologist	100% COST
DIABETES MELLITUS (TYPE 1 AND TYPE 2)*	GP, Physician, Paediatrician, Ophthalmologist, Dietician, Podiatrist, Endocrinologist	100% COST
DYSRHYTHMIA	GP, Physician, Cardiologist, Paediatrician	100% COST
EPILEPSY	GP, Physician, Neurologist, Paediatrician	100% COST
GLAUCOMA	GP, Physician, Ophthalmologist	100% COST
HAEMOPHILIA A & B	GP, Physician, Paediatrician, Haematologist	100% COST
HIV/AIDS**	GP, Physician, Paediatrician	100% COST
HYPERLIPIDAEMIA*	GP, Physician, Cardiologist, Paediatrician, Dietician	100% COST
HYPERTENSION*	GP, Physician, Cardiologist, Dietician	100% COST
HYPOTHYROIDISM	GP, Physician, Paediatrician	100% COST
MULTIPLE SCLEROSIS	GP, Physician, Neurologist, Ophthalmologist, Urologist, Occupational Therapist, Physiotherapist	100% COST
PARKINSON’S DISEASE	GP, Physician, Neurologist	100% COST
Rheumatoid Arthritis	GP, Physician, Rheumatologist, Paediatrician	100% COST
SCHIZOPHRENIA*	Psychiatrist, Clinical Psychologist, Social Worker	100% COST
SYSTEMIC LUPUS ERYTHEMATOSIS	GP, Physician, Dermatologist, Paediatrician	100% COST
ULCERATIVE COLITIS	Gastroenterologist, GP, Physician	100% 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 Plus, Alliance Network, Double Plus, Double Network, Vital Plus and Vital Network

Condition	Consultations	Level of Consultation Cover
ADHD (Alliance Plus & Alliance Network only)	Paediatrician, Neurologist, Psychiatrist	100% CBT
ALLERGIC RHINITIS	GP, Ear Nose and Throat Specialist (ENT), Paediatrician	100% CBT
ALZHEIMER’S DISEASE	Neurologist, Psychiatrist	100% CBT
ANKYLOSING SPONDYLITIS	Physician, Rheumatologist	100% CBT
BENIGN PROSTATIC HYPERTROPHY	Urologist	100% CBT
CHRONIC GRANULOMATOUS DISEASE	Physician	100% CBT
COAGULATION DISORDERS	Cardiologist, Physician, Clinical Haemotologist	100% CBT
CONGENITAL HEART MALFORMATIONS	Physician, Cardiologist, Paediatrician	100% CBT
CYSTIC FIBROSIS	Physician, Physiotherapist, Pulmonologist, Paediatrician, GP	100% CBT
DEEP VEIN THROMBOSIS	Physician	100% CBT
DEPRESSION (includes First Choice, Network Choice, Essential Plus and Essential Network)	GP, Psychiatrist, Clinical Psychologist, Social Worker	100% CBT
ECZEMA	Dermatologist, GP	100% CBT
ENDOMETRIOSIS	Gynaecologist	100% CBT
GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)	GP, Gastroenterologist, Physician, Paediatrician	100% CBT
GAUCHERS DISEASE	Physician, Paediatrician	100% CBT
GOUT PROPHYLAXIS	GP	100% CBT
HORMONE REPLACEMENT	GP	100% CBT
HYPERPARATHYROIDISM	Physician	100% CBT
HYPERTHYROIDISM	GP, Paediatrician	100% CBT
MENIERE’S DISEASE	GP, Ear Nose and Throat Specialist (ENT)	100% CBT
MIGRAINE PROPHYLAXIS	GP, Neurologist	100% CBT
MUSCULAR DYSTROPHY	Neurologist, Physician, Paediatrician	100% CBT
MYASTHENIA GRAVIS	Physician	100% CBT
NARCOLEPSY	Neurologist	100% CBT
ORGAN TRANSPLANT	Appropriate multi disciplinary team	100% CBT
OSTEOARTHRITIS	Physician, Rheumatologist, GP	100% CBT
OSTEOPOROSIS	Physician, Gynaecologist, GP	100% CBT
PLEGIA; HEMI, PARA & QUAD	Physician, Orthopaedic Surgeon, Physiotherapist, Urologist, Neurologist, Occupational Therapist, Paediatrician, Speech Therapist, GP	100% CBT
POLYCYSTIC OVARIAN SYNDROME	Gynaecologist	100% CBT
PSORIASIS	Dermatologist	100% CBT
RESTRICTIVE LUNG DISEASE	Pulmonologist, Physician	100% CBT
TRANSIENT ISCHAEMIC ATTACK / STROKE	Physician, Neurologist	100% CBT
TUBERCULOSIS	GP	100% CBT
VALVULAR HEART DISEASE	Physician, Cardiologist, Paediatrician	100% CBT

ICD10 Codes 2022

Benefit	Practice Type	ICD 10 Codes	ICD 10 Description
GP Consultation	GP (14)	Z00.0	General Medical Examination
		Z00.1	Routine Child Health Examination
		Z00.8	Other General Examinations
		Z01.3	Examination Of Blood Pressure
		Z01.4	Gynaecological Examination (General)(Routine)
		Z10.8	Routine General Health Check-Up Of Other Defined Subpopulations
		Z12.4	Special Screening Examination For Neoplasm Of Cervix
		Z12.5	Special Screening Examination For Neoplasm Of Prostate
		Z13.1	Special Screening Examination For Diabetes Mellitus
		Z13.6	Special Screening Examination For Cardiovascular Disorders
Specialist Consultation	Paediatrician (32)	Z00.0	General Medical Examination
		Z00.1	Routine Child Health Examination
		Z00.8	Other General Examinations
		Z10.8	Routine General Health Check-Up Of Other Defined Subpopulations
Specialist Consultation	Gynaecologist (16)	Z00.0	General Medical Examination
	Specialist Physician (18)	Z00.8	Other General Examinations
	Urologist (46)	Z01.3	Examination Of Blood Pressure
		Z01.4	Gynaecological Examination (General)(Routine)
		Z10.8	Routine General Health Check-Up Of Other Defined Subpopulations
		Z12.4	Special Screening Examination For Neoplasm Of Cervix
		Z12.5	Special Screening Examination For Neoplasm Of Prostate
		Z13.1	Special Screening Examination For Diabetes Mellitus
		Z13.6	Special Screening Examination For Cardiovascular Disorders
Melanoma Screening	Dermatologist (12)	Z12.8	Special Screening Examination for Neoplasm of other sites
		Z12.9	Special Screening Examination for Neoplasm, unspecified
		D22.0	Melanocytic naevi of lip
		D22.1	Melanocytic naevi of eyelid, including canthus
		D22.2	Melanocytic naevi of ear and external auricular canal
		D22.3	Melanocytic naevi of other and unspecified parts of face
		D22.4	Melanocytic naevi of scalp and neck
		D22.5	Melanocytic naevi of trunk
		D22.6	Melanocytic naevi of upper limb, including shoulder
		D22.7	Melanocytic naevi of lower limb, including hip
		D22.9	Melanocytic naevi, unspecified

CAMAF Benefit Option 2022 - Pdf Download

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Glossary

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

ADULT	Refers to the member and dependants who are 22 or older at any time in the year of cover.
CBT	CAMAF 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.
CDL	Chronic 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/ FORMULARY	Condition 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.
CHILD	Refers to a dependant who is younger than an adult, as defined above.
DISPENSING FEES	Fee negotiated by the Scheme with Network pharmacies and added to SEP.
DSP	The 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, Netcare hospital group for Network Choice hospital admissions and Life Healthcare and Netcare hospital groups for Alliance Network, Double Network, Vital Network and Essential Network for hospital admissions.
DTP	The 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 CODE	Stands 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.
INCOME	Total cost to company prior to deductions.
MEDICAL EMERGENCY	A sudden and, at the time, unexpected onset of a health condition or injury that needs immediate attention, where failure to provide such attention could result in the risk of loss of life or permanent damage to a bodily function or body part.
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 and Essential Network options
METABOLIC SCREENING	Newborn screening whereby rare disorders are detected by a blood test done 48 - 72 hours after birth.
MMAP	Maximum 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 RATE	This is the rate, negotiated by the scheme with the service provider/group of service providers, eg. hospitals and pathologists.
NOMINATED GP	Each beneficiary on a Network option needs to nominate a Network GP each year and use that GP only. An alternative nominated GP will be allowed should the primary nominated GP not be available. This is to improve care co-ordination.
PMB	Prescribed 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-AUTHORISATION	A 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.
PROTOCOL	Means 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 CONTRIBUTIONS	Those funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account.
RP	Reference 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.
SEP	Single 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.

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CAMAF BENEFIT OPTION 2022 – PDF DOWNLOAD