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Additional Information
| ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS, MEDICAL AND SURGICAL PROCEDURES INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | 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 | 100% CBT |
| ADVANCED SCANS (MRI/CT/PET) SUBJECT TO PRE-AUTHORISATION | 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. |
| 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. PAEDIATRICIANS FOR UNDER 18's | 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, limited to R2 074 per beneficiary |
| CERVICAL CANCER VACCINE (HPV) (COST OF VACCINE ONLY) | Females between 9 and 45 years of age (SEP plus dispensing fee) |
| 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) |
| MAMMOGRAM | Females from 25 years of age (100% CBT) |
| PAP SMEAR SCREENING | Females between 21 and 65 years of age (100% Negotiated Rate or 100% CBT) |
| ONE HIV VCT TEST | 100% CBT per 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 | 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. |
| 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% CBT limited to R7 980 per beneficiary |
| MEDICATION AND TREATMENT 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 | 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 |
| 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 |
| GPs 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 | 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, HOMEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY | 80% CBT subject to sub-limit R3 110, Subject to limit (c) |
| 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 & LENSES FROM OPTOMETRIST ONLY; ANNUAL BENEFIT, UNLESS OTHERWISE STATED; WHERE PPN IS INDICATED AS THE DSP, PPN RATES & TARIFFS WILL APPLY. FOR ALL OTHER OPTIONS, OPTICAL ASSISTANT RATES | 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 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 R900. |
| RATES | * Monthly income based on Total Cost to Company of Principal Member, Adult R1 313, Adult R2 084, Adult R3 129, Adult R3 934, Adult R4 303, Child R1 234, Child R1 820, Child R2 588, Child R2 808, Child R799, Income Category R0 – R10 960, Income Category R10 961 – R21 140, Income Category R21 141 – R28 340, Income Category R28 341 – R42 520, Income Category R42 521+, Total Monthly Contribution |
