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ESSENTIAL PLUS
Additional Information
| ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS, MEDICAL AND SURGICAL PROCEDURES INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | Up to 200% CBT, 200% CBT |
|---|---|
| SUPPLEMENTARY HEALTHCARE IN HOSPITAL (EG. PHYSIOTHERAPY AND PSYCHOTHERAPY) | 100% CBT |
| BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
| RADIOLOGY IN HOSPITAL | 100% CBT |
| ADVANCED SCANS (MRI/CT/PET) SUBJECT TO PRE-AUTHORISATION | 100% CBT |
| PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
| INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost, 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 benefits apply. |
| CAMAF PREVENTIVE WELLNESS PROGRAMME PER ADULT BENEFICIARY | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy |
| ONE GP CONSULTATION ONLY *ICD 10 CODE SPECIFIC TO GENERAL 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. PAEDIATRICIANS FOR UNDER 18's | 100% CBT per beneficiary |
| PSYCHOTHERAPY | 100% CBT limited to R13 040 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 | |
| ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
| IMMUNISATION AND VACCINES (COST OF IMMUNISATION AND VACCINE ONLY) | SEP plus a dispensing fee, limited to R1 852 per beneficiary |
| CERVICAL CANCER VACCINE (HPV) (COST OF VACCINE ONLY) | Females between 9 and 16 years of age (SEP plus dispensing fee) |
| ONE HIV VCT TEST | 100% CBT per beneficiary |
| ONE MELANOMA SCREENING | 100% CBT per adult beneficiary |
| HOSPITAL ACCOMMODATION (IN HOSPITAL) INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | See In Hospital and Prescribed Minimum Benefits above |
| EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES LIMIT: BREAST PUMPS & APNOEA MONITORS – 3 MONTHS PRIOR TO EXPECTED DUE DATE & WITHIN 6 MONTHS AFTER BIRTH OF BABY. SUBJECT TO REGISTRATION | 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. |
| BASIC AND ADVANCED RADIOLOGY OUT OF HOSPITAL MUST BE PERFORMED BY A REGISTERED RADIOLOGIST, ON REFERRAL FROM MEDICAL PRACTITIONER ONLY. ADVANCED SCANS (MRI/CT/PET) SUBJECT TO PRE-AUTHORISATION | Subject to Medical Savings Account |
| PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER, PRE-AUTHORISATION REQUIRED FOR ADVANCED PATHOLOGY | Subject to Medical Savings Account |
| POST-HOSPITALISATION CONSULTATIONS AND TREATMENT UP TO 90 DAYS | Subject to Medical Savings Account |
| MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS (SUBJECT TO PRE-AUTHORISATION) REFER TO ADDITIONAL CHRONIC CONDITIONS LIST | Depression only. 100% SEP plus a dispensing fee subject to RP and DSP Consultations 100% CBT |
| EXTERNAL APPLIANCES (subject to referral); IN & OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE; CPAP (subject to pre-authorisation) - 3 YEAR CYCLE; HEARING AIDS (subject to pre-authorisation) - 1 CLA | Subject to Medical Savings Account |
| INTERNATIONAL TRAVEL COVER PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND SUBJECT TO THEIR POLICY REQUIREMENTS. ARRANGE COVER PRIOR TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS. | R10 million per beneficiary per journey for emergency medical costs while you travel outside South Africa., This cover is for a period of 90 days from your departure from South Africa. Cover for pre-existing conditions is limited to R150,000 unless additional cover is arranged., The cover is available to members who are not older than 80 years of age. |
| NETCARE 911 EMERGENCY SERVICES | Unlimited, Subject to Netcare 911 authorisation |
| DAY-TO-DAY BENEFITS: BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT | Limited to funds available in the beneficiary’s Medical Savings Account |
| GPs AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY | Subject to Medical Savings Account |
| SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS | Subject to Medical Savings Account |
| ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS | Subject to Medical Savings Account |
| CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT | Subject to Medical Savings Account |
| NURSE VISITS | Subject to Medical Savings Account |
| SUPPLEMENTARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY | Subject to Medical Savings Account |
| 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 |
| RATES | Adult R1 542, Adult R1 858, Adult R2 012, Adult R2 328, Adult R470, Child R1 087, Child R1 186, Child R1 367, Child R280, Child R906, Income Category R0 – R115 310, Income Category R115 311+, Principal R1 951, Principal R2 344, Principal R2 541, Principal R2 934, Principal R590, Monthly MSA Contribution, Total Monthly Contribution, Monthly income based on Total Cost to Company of Principal Member |
