CAMAF Benefit Brochure 2023

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

CAMAF BENEFIT OPTION 2023 – PDF DOWNLOAD

CAMAF Benefit Option Summary

CAMAF Benefit Options: Quick Summary


Hospital Facility Fees	Alliance Plus Any private hospital. Private wards for confinements (subject to availability). Alliance Network Life Healthcare, Netcare. Private wards for confinements (subject to availability).	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	65 Conditions List of conditions Additional conditions	64 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
Preventive 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)	R39 500	R15 390	-	Limited to funds available in the beneficiary’s Medical Savings Account	R3 700 for medicines. R7 755 for advanced dentistry. R11 390 for specialists. R3 700 for other. Paid at 80%	R3 700 for medicines. R7 755 for advanced dentistry. R11 390 for specialists. R3 700 for other. Paid at 100% 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 932 Essential Network: R7 164	-	-

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 (20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies) – no limits, private wards for confinements (subject to availability)
	Attending Doctors and Specialists: 300% CBT
	65 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: Melanoma, PSA, Pap Smear, Mammogram
	3 Months 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)
	Checkups and Vaccines: GP (nominated network GP referral applies for Alliance Network), Specialist, Dental, Optometry (PPN optometrist for Alliance Network), Dermatologist, ECG, Dietician
	Infertility R100 765 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 (PROFESSIONAL NURSES ONLY; FRAIL CARE EXCLUDED)	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 R100 765 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 PRE-AUTHORISATION AND ICON Protocols#	Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 300% CBT. The DSP is the ICON network. The ICON Enhanced protocols apply.

#Please refer to website for ICON benefit structures.

ALLIANCE PLUS & ALLIANCE NETWORK

PREVENTIVE WELLNESS COVER
CAMAF PREVENTIVE WELLNESS 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 CHECKUP ONLY	100% CBT per beneficiary. (Nominated Network GP for Alliance Network)
ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R14 930 per beneficiary
ONE DIETICIAN CONSULTATION	100% CBT per beneficiary
ONE DENTISTRY CONSULTATION GENERAL CHECKUP ONLY - excludes consumables	100% CBT per beneficiary
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R6 247 per beneficiary
HUMAN PAPILLOMA VIRUS (HPV) VACCINE (COST OF VACCINE ONLY)	Females between 9 and 45 years of age. Males between 9 and 26 years of age. Includes initial vaccination and two follow-up booster vaccinations, where applicable. (SEP plus dispensing fee)
PSA SCREENING	Males older than 40 years of age (100% Negotiated Rate or CBT)
PAP SMEAR SCREENING	Females between 21 and 65 years of age (100% Negotiated Rate or 100% CBT)
MAMMOGRAM	Females from 25 years of age (100% CBT)
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: R3 181 Breast pumps: R5 205
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 R3 045 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; medication claims will not be paid if non-nominated network GP is used)
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 R101 725 per beneficiary and subject to the following sub-limits: Hearing Aids: R101 725 Wheelchairs for Quadriplegics: R101 725 Standard Wheelchairs: R60 695 Insulin Pumps: R60 695 Other external appliances: R20 140 (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 of South Africa, and have a policy in place before departing. This cover is for a maximum period of 90 days from your departure from South Africa and ceases upon your return to South Africa. The cover is available to beneficiaries who are not older than 80 years of age. Cover for pre-existing conditions is only available for members who have not yet turned 70 years of age and is limited to R250 000 in-hospital cover, unless additional cover is arranged. Refer to Travel Policy Wording.
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 R39 500 Child R24 600
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, HOMEOPATHS, 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 R20 140 M1 R30 100 M2+ R36 300
OVER THE COUNTER MEDICATION	80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R4 970 per beneficiary
LASER K/EXCIMER LASER NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS	80% CBT limited to R15 250 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 Preventive Wellness Benefit Add-ons R1 975 Single vision R1 975 OR Bifocal R3 960 OR Varifocal R5 960 AND Frames R8 890 OR Contact lenses R8 640 Lenses, frames etc 80% Optical Assistant Rates PPN is the DSP for Alliance Network

ALLIANCE PLUS & ALLIANCE NETWORK

MONTHLY CONTRIBUTION RATES

Monthly Risk Contribution	Adult Child	R6 996 R3 793	R6 345 R3 438
Monthly MSA Contribution	Adult Child	R 622 R 286	R 565 R 260
Total Monthly Contribution	Adult Child	R7 618 R4 079	R6 910 R3 698

Benefit Option: Double Plus & Double Network

	Double Plus: Any Private Hospital: No limits. Double Network: Life Healthcare, Netcare: (20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies) – No limits.
	Attending Doctors 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 Benefits Melanoma, PSA, Pap Smear, Mammogram
	3 Months 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)
	Checkups and Vaccines: GP (nominated network GP referral applies for Double Network), Specialist, Dental, Optometry (PPN optometrist for Double Network), ECG
	Infertility R71 065 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 (PROFESSIONAL NURSES ONLY; FRAIL CARE EXCLUDED)	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 R71 065 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 PRE-AUTHORISATION AND ICON Protocols#	Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 300% CBT The DSP is the ICON network. The ICON Core protocols apply.

#Please refer to website for ICON benefit structures.

DOUBLE PLUS & DOUBLE NETWORK

PREVENTIVE WELLNESS COVER
CAMAF PREVENTIVE 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 CHECKUP ONLY	100% CBT per beneficiary (nominated Network GP for Double Network)
ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R14 930 per beneficiary
ONE DIETICIAN CONSULTATION	100% CBT per beneficiary
ONE DENTISTRY CONSULTATION GENERAL CHECKUP ONLY - excludes consumables	100% CBT per beneficiary
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R3 138 Child R5 151
HUMAN PAPILLOMA VIRUS (HPV) VACCINE (COST OF VACCINE ONLY)	Females between 9 and 45 years of age. Males between 9 and 26 years of age. Includes initial vaccination and two follow-up booster vaccinations, where applicable. (SEP plus dispensing fee)
PSA SCREENING	Males older than 40 years of age (100% Negotiated Rate or CBT)
PAP SMEAR SCREENING	Females between 21 and 65 years of age (100% Negotiated Rate or CBT)
MAMMOGRAM	Females from 25 years of age (100% CBT)
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: R3 125 Breast pumps: R5 205
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 232 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; medication claims will not be paid if non-nominated network GP is used)
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 R81 324 per beneficiary and subject to the following sub-limits: Hearing Aids: R81 324 Wheelchairs for Quadriplegics: R81 324 Standard Wheelchairs: R51 870 Insulin Pumps: R53 110 Other external appliances: R17 440 (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 of South Africa, and have a policy in place before departing. This cover is for a maximum period of 90 days from your departure from South Africa and ceases upon your return to South Africa. The cover is available to beneficiaries who are not older than 80 years of age. Cover for pre-existing conditions is only available for members who have not yet turned 70 years of age and is limited to R250 000 in-hospital cover, unless additional cover is arranged. Refer to Travel Policy Wording.
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 R15 390 Child R10 680
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, HOMEOPATHS, 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 R15 000 M1 R21 600 M2+ R29 090
OVER THE COUNTER MEDICATION	80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R2 205 per beneficiary
LASER K/EXCIMER LASER NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS	80% CBT limited to R5 630 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 Preventive Wellness Benefit Add ons R1 300 Single vision R1 300 OR Bifocal R3 470 OR Varifocal R5 320 AND Frames R4 780 OR Contact lenses R4 640 Lenses, frames etc 80% Optical Assistant Rates PPN is the DSP for Double Network

DOUBLE PLUS & DOUBLE NETWORK

MONTHLY CONTRIBUTION RATES

Monthly Risk Contribution	Adult Child	R4 630 R2 653	R4 225 R2 422
Monthly MSA Contribution	Adult Child	R 400 R 257	R 365 R 234
Total Monthly Contribution	Adult Child	R5 030 R2 910	R4 590 R2 656

Benefit Option: Vital Plus & Vital Network

	Vital Plus: Any Private Hospital: No limits. Vital Network: Life Healthcare, Netcare: (20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies) – 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: Melanoma, PSA, Pap Smear, Mammogram
	3 Months post-hospitalisation benefit
	External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor
	Checkups 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 (PROFESSIONAL NURSES ONLY; FRAIL CARE EXCLUDED)	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 PRE-AUTHORISATION AND ICON PROTOCOLS#	Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 300% CBT The DSP is the ICON network. The ICON Core protocols apply.

#Please refer to website for ICON benefit structures

VITAL PLUS & VITAL NETWORK

PREVENTIVE WELLNESS COVER
CAMAF PREVENTIVE WELLNESS 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 CHECKUP ONLY	100% CBT per beneficiary
ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R14 930 per beneficiary
ONE DIETICIAN CONSULTATION	100% CBT per beneficiary
ONE DENTISTRY CONSULTATION GENERAL CHECKUP ONLY - excludes consumables	100% CBT per beneficiary
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R2 079 per beneficiary
HUMAN PAPILLOMA VIRUS (HPV) VACCINE (COST OF VACCINE ONLY)	Females between 9 and 45 years of age. Males between 9 and 26 years of age. Includes initial vaccination and two follow-up booster vaccinations, where applicable. (SEP plus dispensing fee)
PSA SCREENING	Males older than 40 years of age (100% Negotiated Rate or CBT)
PAP SMEAR SCREENING	Females between 21 and 65 years of age (100% Negotiated Rate or CBT)
MAMMOGRAM	Females from 25 years of age (100% CBT)
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: R3 120 Breast pumps: R5 205
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 R46 805 per beneficiary and subject to the following sub-limits: Hearing Aids: R40 670 Wheelchairs for Quadriplegics: R40 675 Standard Wheelchairs: R28 565 Insulin Pumps: R46 805 Other external appliances: R10 195
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 of South Africa, and have a policy in place before departing. This cover is for a maximum period of 90 days from your departure from South Africa and ceases upon your return to South Africa. The cover is available to beneficiaries who are not older than 80 years of age. Cover for pre-existing conditions is only available for members who have not yet turned 70 years of age and is limited to R250 000 in-hospital cover, unless additional cover is arranged. Refer to Travel Policy Wording.
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, HOMEOPATHS, 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 Preventive Wellness

VITAL PLUS & VITAL NETWORK

MONTHLY CONTRIBUTION RATES

Monthly income based on Total Cost to Company of Principal Member		Total Monthly Contribution
R0 - R51 420	Adult Child	R2 666 R1 367	R2 481 R1 272
R51 421 – R128 560	Adult Child	R3 022 R1 542	R2 813 R1 436
R128 561+	Adult Child	R3 361 R1 722	R3 129 R1 603

Benefit Option: Essential Plus & Essential Network

	Essential Plus: Any Private Hospital: No limits. Essential Network: Life Healthcare, Netcare: (20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies) – 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: Melanoma, PSA, Pap Smear, Mammogram
	Checkups 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 (PROFESSIONAL NURSES ONLY; FRAIL CARE EXCLUDED)	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 PRE-AUTHORISATION 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 protocols apply.

#Please refer to website for ICON benefit structures

ESSENTIAL PLUS & ESSENTIAL NETWORK

PREVENTIVE WELLNESS COVER
CAMAF PREVENTIVE WELLNESS 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 CHECKUP ONLY	100% CBT per beneficiary
ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R14 930 per beneficiary
ONE DIETICIAN CONSULTATION	100% CBT per beneficiary
ONE DENTISTRY CONSULTATION GENERAL CHECKUP ONLY - excludes consumables	100% CBT per beneficiary
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R2 074 per beneficiary
HUMAN PAPILLOMA VIRUS (HPV) VACCINE (COST OF VACCINE ONLY)	Females between 9 and 45 years of age. Males between 9 and 26 years of age. Includes initial vaccination and two follow-up booster vaccinations, where applicable. (SEP plus dispensing fee)
PSA SCREENING	Males older than 40 years of age (100% Negotiated Rate or CBT)
PAP SMEAR SCREENING	Females between 21 and 65 years of age (100% Negotiated Rate or CBT)
MAMMOGRAM	Females from 25 years of age (100% CBT)
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 of South Africa, and have a policy in place before departing. This cover is for a maximum period of 90 days from your departure from South Africa and ceases upon your return to South Africa. The cover is available to beneficiaries who are not older than 80 years of age. Cover for pre-existing conditions is only available for members who have not yet turned 70 years of age and is limited to R250 000 in-hospital cover, unless additional cover is arranged. Refer to Travel Policy Wording.
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, HOMEOPATHS, 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

ESSENTIAL PLUS & ESSENTIAL NETWORK

MONTHLY CONTRIBUTION RATES

Monthly income based on Total Cost to Company of Principal Member		Total Monthly Contribution
R0 - R128 560
Monthly Risk Contribution	Principal Adult Child	R2 188 R1 730 R1 016	R1 973 R1 559 R 917
Monthly MSA Contribution	Principal Adult Child	R 661 R 527 R 314	R 597 R 473 R 282
Total Monthly Contribution	Principal Adult Child	R2 849 R2 257 R1 330	R2 570 R2 032 R1 199
R128 561+
Monthly Risk Contribution	Principal Adult Child	R2 634 R2 088 R1 222	R2 376 R1 884 R1 102
Monthly MSA Contribution	Principal Adult Child	R 661 R 527 R 314	R 597 R 473 R 282
Total Monthly Contribution	Principal Adult Child	R3 295 R2 615 R1 536	R2 973 R2 357 R1 384

Benefit Option: First Choice

	Any Private Hospital: No limits
	Attending Doctors 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 R42 755 per family for in and out of hospital
	Screening Benefits: PSA, Pap Smear, Mammogram
	80% of GP, Specialists, Dental, Optometry, Checkups, 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 R42 755 per family (combined limit for in and out hospital)
PATHOLOGY IN HOSPITAL	100% Negotiated Rate
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION	100% of cost limited to R42 755 per family Exclusions: cochlear implants
HOME NURSING UP TO 21 DAYS, SUBJECT TO PRE-AUTHORISATION (PROFESSIONAL NURSES ONLY; FRAIL CARE EXCLUDED)	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 PRE-AUTHORISATION 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 protocols apply.

#Please refer to website for ICON benefit structures.

FIRST CHOICE

PREVENTIVE WELLNESS COVER
CAMAF PREVENTIVE WELLNESS 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 CHECKUP ONLY	100% CBT per beneficiary
ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R14 930 per beneficiary
ONE DENTISTRY CONSULTATION GENERAL CHECKUP ONLY - excludes consumables	100% CBT per beneficiary
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R2 074 per beneficiary
HUMAN PAPILLOMA VIRUS (HPV) VACCINE (COST OF VACCINE ONLY)	Females between 9 and 45 years of age. Males between 9 and 26 years of age. Includes initial vaccination and two follow-up booster vaccinations, where applicable. (SEP plus dispensing fee)
PSA SCREENING	Males older than 40 years of age (100% Negotiated Rate or CBT)
PAP SMEAR SCREENING	Females between 21 and 65 years of age (100% Negotiated Rate or CBT)
MAMMOGRAM	Females from 25 years of age (100% CBT)
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 550 Breast pumps: R4 385
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 175 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 R5 000 per beneficiary Advanced scans: 100% CBT limited to R42 755 per family for in and out of hospital
PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER	100% Negotiated Rate limited to R7 980 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 635 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 of South Africa, and have a policy in place before departing. This cover is for a maximum period of 90 days from your departure from South Africa and ceases upon your return to South Africa. The cover is available to beneficiaries who are not older than 80 years of age. Cover for pre-existing conditions is only available for members who have not yet turned 70 years of age and is limited to R250 000 in-hospital cover, unless additional cover is arranged. Refer to Travel Policy Wording.
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 700 (b) Advanced Dentistry R7 755 (c) Other R3 700 (d) Specialists R11 390
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 R3 110 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 900 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 R900. 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 R215 per lens or one pair of clear flat top bifocal spectacle lenses limited to R460 per lens or one pair of clear flat top Multifocal lenses limited to R810 per lens OR CONTACT LENSES - Contact Lenses to the value of R900.

FIRST CHOICE

MONTHLY CONTRIBUTION RATES

Monthly income based on Total Cost to Company of Principal Member		Total Monthly Contribution
R0 - R10 960	Adult Child	R1 313 R 799
R10 961 - R21 140	Adult Child	R2 084 R1 234
R21 141 - R28 340	Adult Child	R3 129 R1 820
R28 341 - R42 520	Adult Child	R3 934 R2 588
R42 521+	Adult Child	R4 303 R2 808

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 R42 755 per family for in and out of hospital
	Screening Benefits: PSA, Pap Smear, Mammogram
	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 R42 755 per family (combined limit for in and out hospital)
PATHOLOGY IN HOSPITAL	100% Negotiated Rate
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION	100% of cost limited to R42 755 per family Exclusions: cochlear implants
HOME NURSING UP TO 21 DAYS, SUBJECT TO PRE-AUTHORISATION (PROFESSIONAL NURSES ONLY; FRAIL CARE EXCLUDED)	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 (on referral from a nominated network GP)
PMB DTP TREATMENT OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF CONDITION AND PRE-AUTHORISATION	Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - as per PMB regulations (on referral from a nominated network GP)
ONCOLOGY SUBJECT TO PRE-AUTHORISATION 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 protocols apply.

#Please refer to website for ICON benefit structures

NETWORK CHOICE

PREVENTIVE WELLNESS COVER
CAMAF PREVENTIVE WELLNESS 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 CHECKUP ONLY	100% CBT per beneficiary (Nominated Network GP only)
ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R14 930 per beneficiary
ONE DENTISTRY CONSULTATION GENERAL CHECKUP ONLY - excludes consumables	100% CBT per beneficiary
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP 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 R2 074 per beneficiary
HUMAN PAPILLOMA VIRUS (HPV) VACCINE (COST OF VACCINE ONLY)	Females between 9 and 45 years of age. Males between 9 and 26 years of age. Includes initial vaccination and two follow-up booster vaccinations, where applicable. (SEP plus dispensing fee)
PSA SCREENING	Males older than 40 years of age (100% Negotiated Rate or CBT)
PAP SMEAR SCREENING	Females between 21 and 65 years of age (100% Negotiated Rate or CBT)
MAMMOGRAM	Females from 25 years of age (100% CBT)
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 550 Breast pumps: R4 385
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 175 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 R5 000 per beneficiary Advanced scans: 100% CBT limited to R42 755 per family for in and out of hospital (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 980 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 (on referral from a nominated network; medication claims will not be paid if non-nominated network GP is used)
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 635 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 of South Africa, and have a policy in place before departing. This cover is for a maximum period of 90 days from your departure from South Africa and ceases upon your return to South Africa. The cover is available to beneficiaries who are not older than 80 years of age. Cover for pre-existing conditions is only available for members who have not yet turned 70 years of age and is limited to R250 000 in-hospital cover, unless additional cover is arranged. Refer to Travel Policy Wording.
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 700 (b) Advanced Dentistry R7 755 (c) Other R3 700 (d) Specialists R11 390
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	Both benefits below are limited to an overall family limit of R1 580. One non-network or non-nominated visit per beneficiary (Including casualty GP), 20% co-payment AND Casualty visits (facility fee, consumed meds and materials only)
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT
NURSE VISITS	100% CBT subject to limit (c)
SUPPLEMENTARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY	100% CBT limited to R3 110 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 900 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 R900. 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 R215 per lens or one pair of clear flat top bifocal spectacle lenses limited to R460 per lens or one pair of clear flat top Multifocal lenses limited to R810 per lens OR CONTACT LENSES - Contact Lenses to the value of R900.

NETWORK CHOICE

MONTHLY CONTRIBUTION RATES

Monthly income based on Total Cost to Company of Principal Member		Total Monthly Contribution
R0 - R21 140	Principal Adult 1st Child (rest are free)	R1 869 R1 563 R 813
R21 141 - R28 340	Principal Adult 1st Child (rest are free)	R2 222 R1 774 R 999
R28 341 - R42 520	Principal Adult Child	R2 659 R2 060 R1 325
R42 521+	Principal Adult Child	R3 572 R2 882 R1 754

Monthly Contribution Rates

Monthly Risk Contribution
Adult R6 996
Child R3 793

Monthly MSA Contribution
Adult R 622
Child R 286

Total Monthly Contribution
Adult R7 618
Child R4 079

Monthly Risk Contribution
Adult R6 345
Child R3 438

Monthly MSA Contribution
Adult R 565
Child R 260

Total Monthly Contribution
Adult R6 910
Child R3 698

Monthly Risk Contribution
Adult R4 630
Child R2 653

Monthly MSA Contribution
Adult R 400
Child R 257

Total Monthly Contribution
Adult R5 030
Child R2 910

Monthly Risk Contribution
Adult R4 225
Child R2 422

Monthly MSA Contribution
Adult R 365
Child R 234

Total Monthly Contribution
Adult R4 590
Child R2 656

Total monthly contribution for a monthly income ¹ of
R0 - R51 420
Adult R2 666
Child R1 367

Total monthly contribution for a monthly income ¹ of
R51 421 - R128 560
Adult R3 022
Child R1 542

Total monthly contribution for a monthly income ¹ of
R128 561+
Adult R3 361
Child R1 722

Total monthly contribution for a monthly income ¹ of
R0 - R51 420
Adult R2 481
Child R1 272

Total monthly contribution for a monthly income ¹ of
R51 421 - R128 560
Adult R2 813
Child R1 436

Total monthly contribution for a monthly income ¹ of
R128 561+
Adult R3 129
Child R1 603

R0 - R128 560 ¹

Monthly Risk Contribution
Principal R2 188
Adult R1 730
Child R1 016

Monthly MSA Contribution
Principal R661
Adult R527
Child R314

Total Monthly Contribution
Principal R2 849
Adult R2 257
Child R1 330

R128 561+ ¹

Monthly Risk Contribution
Principal R2 634
Adult R2 088
Child R1 222

Monthly MSA Contribution
Principal R661
Adult R527
Child R314

Total Monthly Contribution
Principal R3 295
Adult R2 615
Child R1 536

R0 - R128 560 ¹

Monthly Risk Contribution
Principal R1 973
Adult R1 559
Child R917

Monthly MSA Contribution
Principal R597
Adult R473
Child R282

Total Monthly Contribution
Principal R2 570
Adult R2 032
Child R1 199

R128 561+ ¹

Monthly Risk Contribution
Principal R2 376
Adult R1 884
Child R1 102

Monthly MSA Contribution
Principal R597
Adult R473
Child R282

Total Monthly Contribution
Principal R2 973
Adult R2 357
Child R1 384

Total monthly contribution for a monthly income ¹ of
R0 - R10 960
Adult R1 313
Child R799

Total monthly contribution for a monthly income ¹ of
R10 961 - R21 140
Adult R2 084
Child R1 234

Total monthly contribution for a monthly income ¹ of
R21 141 - R28 340
Adult R3 129
Child R1 820

Total monthly contribution for a monthly income ¹ of
R28 341 - R42 520
Adult R3 934
Child R2 588

Total monthly contribution for a monthly income ¹ of
R42 521+
Adult R4 303
Child R2 808

Total monthly contribution for a monthly income ¹ of
R0 - R21 140
Principal R1 869
Adult R1 563
1st Child R813
(rest are free)

Total monthly contribution for a monthly income ¹ of
R21 141 - R28 340
Principal R2 222
Adult R1 774
1st Child R999
(rest are free)

Total monthly contribution for a monthly income ¹ of
R28 341 - R42 520
Principal R2 659
Adult R2 060
Child R1 325

Total monthly contribution for a monthly income ¹ of
R42 521+
Principal R3 572
Adult R2 882
Child R1 754

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

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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 (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY)	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 (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY)	Neurologist	100% CBT
ORGAN TRANSPLANT	Appropriate multi disciplinary team	100% CBT
OSTEOARTHRITIS	Physician, Rheumatologist, GP	100% CBT
OSTEOPOROSIS	Physician, Gynaecologist, GP	100% CBT
PERVASIVE DEVELOPMENTAL DISORDER (PDD) (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY)	GP, Pediatrician, Neurologist, Psychiatrist	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 (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY)	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 2023

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 2023 - Pdf Download

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Glossary

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 26 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).
Child	Refers to a dependant who is younger than an adult, as defined above.
Childbirth Confinement	The period of time just before and during the birth of a child
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.
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 271 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	International Classification of Diseases and Related Health Problems (10th revision) - 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.
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.
MSA	Medical Savings Account - 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
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 Alliance Network, Double Network and Network Choice options 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 271 medical conditions (Defined in DTP’s) • 26 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 - 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.

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

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