This brochure is for summary purposes only and does not supersede the rules of the Scheme in any way.
This brochure is for summary purposes only and does not supersede the rules of the Scheme in any way.
Hospital Facility Fees | Any private hospital. Private wards | Any private hospital | Any private hospital | Any private hospital | Any private hospital | Netcare hospitals only |
Attending Doctor’s and Specialists in Hospital | Up to 300% CBT | Up to 300% CBT | Up to 300% CBT | Up to 200% CBT | Up to 100% CBT | Up to 100% CBT |
Chronic condition cover: medicines and consults | 64 Conditions List of conditions Additional conditions | 63 Conditions List of conditions Additional conditions | 63 Conditions List of conditions Additional conditions | 27 Conditions List of conditions | 27 Conditions List of conditions | 27 Conditions List of conditions |
Radiology and Pathology | Unlimited In or Out of Hospital | Unlimited In or Out of Hospital | Unlimited In or Out of Hospital | Unlimited In Hospital, Out of Hospital from MSA | Limits apply In and Out of Hospital | Limits apply In and Out of Hospital |
Preventative Wellness Benefits | 14 extra benefits | 14 extra benefits | 14 extra benefits | 14 extra benefits | 10 extra benefits | 10 extra benefits |
Day to Day Overall Limit (Principal Member) | R35 100 | R13 659 | - | - | R3 290 for Medicines. R10 120 for Specialists. R3 290 for Other. Paid at 80% | R3 290 for Medicines. R10 120 for Specialists. R3 290 for Other. From DSP only |
Medical Savings Account (Principal Member) | R7 320 | R4 704 | - | R7 080 | - | - |
Any Private Hospital: No limits, private wards for confinements (subject to availability) | |
Attending Dr’s and Specialists: Up to 300% CBT | |
64 Chronic Conditions medication and consultations. Includes unlimited appropriate biological drugs and specialised technology | |
Unlimited X-Rays and Blood Tests IN and OUT of hospital including MRI and CT scans | |
Screening Benefit | |
3 Month post hospitalisation benefit | |
External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor | |
Check-Ups and Vaccines: GP, Specialist, Dental, Optometry, Dermatologist, ECG, Dietician | |
Infertility R89 600 per family |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
IN HOSPITAL AND PRESCRIBED MINIMUM BENEFITS | |
---|---|
HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | 100% of Negotiated Rate in general ward and specialised units. Private ward for confinements (subject to availability). |
ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS, MEDICAL AND SURGICAL PROCEDURES INCLUDING CONFINEMENTS | Up to 300% CBT 300% CBT |
SUPPLEMENTARY HEALTHCARE IN HOSPITAL | 100% CBT |
BLOOD TRANSFUSIONS(IN AND OUT OF HOSPITAL) | 100% of cost |
RADIOLOGY IN HOSPITAL | 100% CBT 100% CBT |
PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost |
HOME NURSING | 100% CBT |
STEP-DOWN/PHYSICAL REHABILITATION APPROVED FACILITIES ONLY, UP TO 90 DAYS (SUBJECT TO PRE-AUTHORISATION) | 100% Negotiated Rate |
MEDICATION IN HOSPITAL | 100% SEP plus dispensing fee |
TTO MEDICATION UP TO ONE WEEK’S SUPPLY | 100% SEP plus dispensing fee |
INFERTILITY TREATMENT | Treatment limited to R89 600 per family |
SUBSTANCE ABUSE | PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days |
CHRONIC PMB CDL MEDICATION AND TREATMENT - SUBJECT TO PRE-AUTHORISATION, PROTOCOLS AND FORMULARIES | 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - as per PMB regulations |
PMB DTP TREATMENT | Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - as per PMB regulations |
ONCOLOGY | Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 300% CBT The ICON Enhanced benefits apply |
#Please refer to website for ICON benefit structures.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
PREVENTATIVE WELLNESS COVER | |
---|---|
CAMAF PREVENTATIVE PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary. |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R13 040 per beneficiary |
ONE DIETICIAN CONSULTATION | 100% CBT per beneficiary |
ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY - excludes consumables | 100% CBT per beneficiary |
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, limited to R5 565 per beneficiary |
CERVICAL CANCER VACCINE (HPV) | Females between 9 and 16 years of age (SEP plus dispensing fee) |
ONE HIV VCT TEST | 100% CBT per beneficiary |
MELANOMA SCREENING | 100% CBT per adult beneficiary |
*Refer to website for relevant ICD 10 codes.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
MATERNITY BENEFITS | |
---|---|
HOSPITAL ACCOMMODATION | See In Hospital and Prescribed Minimum Benefits above |
EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES | Baby Apnoea Monitors: R2 830 Breast pumps: R4 630 |
METABOLIC SCREENING FOR NEW BORN BABIES | 100% Negotiated Rate per new born baby |
ANTE-NATAL FOETAL SCANS PER PREGNANCY | 6 scans at 80% CBT Subject to Annual Overall Day-to-Day Limit |
ANTE-NATAL CLASSES | 80% CBT limited to R2 707 per pregnancy Subject to Annual Overall Day-to-Day Limit |
UMBLICAL STEM CELL HARVESTING | Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits. |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
BASIC AND ADVANCED RADIOLOGY | 100% CBT |
PATHOLOGY | 100% Negotiated Rate or CBT |
POST-HOSPITALISATION | 300% CBT for attending practitioners 100% CBT for supplementary services |
MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS | 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT |
EXTERNAL APPLIANCES (subject to referral) | 100% NAPPI price or 100% of cost, subject to the overall limit of R90 400 per beneficiary and subject to the following sub-limits: Hearing Aids: R90 400 Wheelchairs for Quadriplegics: R90 400 Standard Wheelchairs: R54 000 Insulin Pumps: R54 000 Other external appliances: R17 900 |
INTERNATIONAL TRAVEL COVER | 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 | Unlimited Subject to Netcare 911 authorisation |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
DAY TO DAY BENEFITS | Annual Overall Limits Adult R35 100 Child R21 900 |
GPs AND DENTISTS | 80% CBT |
SPECIALISTS | 80% CBT |
ACUTE MEDICATION | 80% SEP plus dispensing fee, subject to MMAP, co-payment from MSA |
NON-DSP VISITS | Not applicable |
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL | 80% CBT |
NURSE VISITS | 80% CBT up to 21 days |
SUPPLEMENTARY HEALTH | 80% CBT |
ADVANCED DENTISTRY | 80% CBT limited to: M0 R17 900 M1 R26 800 M2+ R32 200 |
OVER THE COUNTER MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R4 500 per beneficiary |
LASER K/EXCIMER LASER | 80% CBT limited to R13 550 per beneficiary per eye |
SPECTACLES AND LENSES | Consultation: See Preventative Wellness Benefit Add ons R1 760 Single vision R1 760 OR Bifocal R3 520 OR Varifocal R5 300 AND Frames R7 900 OR Contact lenses R7 680 Lenses, frames etc 80% Optical Assistant Rates |
Monthly Risk Contribution | Adult Child | R6 116 R3 325 |
Monthly MSA Contribution | Adult Child | R 610 R 280 |
Total Monthly Contribution | Adult Child | R6 726 R3 605 |
Any Private Hospital: No limits | |
Attending Dr’s and Specialists: Up to 300% CBT | |
63 Chronic Conditions Medication and Consultations. Includes unlimited appropriate Biological Drugs and Specialised Technology |
|
Unlimited X-rays and Blood Tests In and Out of Hospital including MRI and CT Scans | |
Screening Benefits | |
3 Month Post Hospitalisation Benefit | |
External Appliances: wheelchair, hearing aid, breast pump, baby sleep monitor | |
Check-ups and Vaccines: GP, Specialist, Dental, Optometry, ECG | |
Infertility R63 200 per family |
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, | 100% of Negotiated Rate in general ward and specialised units. |
ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS | Up to 300% CBT 300% CBT |
SUPPLEMENTARY HEALTHCARE IN HOSPITAL | 100% CBT |
BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
RADIOLOGY IN HOSPITAL | 100% CBT 100% CBT |
PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost |
HOME NURSING | 100% CBT |
STEP-DOWN/PHYSICAL REHABILITATION APPROVED | 100% Negotiated Rate |
MEDICATION IN HOSPITAL | 100% SEP plus dispensing fee |
TTO MEDICATION UP TO ONE WEEK’S SUPPLY | 100% SEP plus dispensing fee |
INFERTILITY TREATMENT | Treatment limited to R63 200 per family |
SUBSTANCE ABUSE | PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days |
CHRONIC PMB CDL MEDICATION AND TREATMENT - SUBJECT | 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - as per PMB regulations |
PMB DTP TREATMENT | Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - as per PMB regulations |
ONCOLOGY | Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 300% CBT The ICON Core benefits apply |
#Please refer to website for ICON benefit structures.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
PREVENTATIVE WELLNESS COVER | |
---|---|
CAMAF PREVENTATIVE PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R13 040 per beneficiary |
ONE DIETICIAN CONSULTATION | 100% CBT per beneficiary |
ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY - excludes consumables | 100% CBT per beneficiary |
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, limited to: Adults R2 790 - Child R4 622 |
CERVICAL CANCER VACCINE (HPV) | Females between 9 and 16 years of age (SEP plus dispensing fee) |
ONE HIV VCT TEST | 100% CBT per beneficiary |
MELANOMA SCREENING | 100% CBT per adult beneficiary |
*Refer to website for relevant ICD 10 codes.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
MATERNITY BENEFITS | |
---|---|
HOSPITAL ACCOMMODATION | See In Hospital and Prescribed Minimum Benefits above |
EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES | Baby Apnoea Monitors: R2 780 Breast pumps: R4 630 |
METABOLIC SCREENING FOR NEW BORN BABIES | 100% Negotiated Rate per new born baby |
ANTE-NATAL FOETAL SCANS PER PREGNANCY | 4 scans at 80% CBT Subject to Annual Overall Day-to-Day Limit |
ANTE-NATAL CLASSES | 80% CBT limited to R1 983 per pregnancy Subject to Annual Overall Day-to-Day Limit |
UMBLICAL STEM CELL HARVESTING | Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits. |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
BASIC AND ADVANCED RADIOLOGY | 100% CBT |
PATHOLOGY | 100% Negotiated Rate or CBT |
POST-HOSPITALISATION | 300% CBT for attending practitioners 100% CBT for supplementary services |
MEDICATION FOR ADDITIONAL | 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT |
EXTERNAL APPLIANCES (subject to referral) | 100% NAPPI price or 100% of cost, subject to the overall limit of R72 300 per beneficiary and subject to the following sub-limits: Hearing Aids: R72 300 Wheelchairs for Quadriplegics: R72 300 Standard Wheelchairs: R46 100 Insulin Pumps: R47 200 Other external appliances: R15 500 |
INTERNATIONAL TRAVEL COVER | 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 | Unlimited Subject to Netcare 911 authorisation |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
DAY TO DAY BENEFITS | Annual Overall Limits Adult R13 659 Child R 9 491 |
GPs AND DENTISTS | 80% CBT |
SPECIALISTS | 80% CBT |
ACUTE MEDICATION | 80% SEP plus dispensing fee, subject to MMAP, co-payment from MSA |
NON-DSP VISITS | Not applicable |
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL | 80% CBT |
NURSE VISITS | 80% CBT up to 21 days |
SUPPLEMENTARY HEALTH | 80% CBT |
ADVANCED DENTISTRY | 80% CBT limited to: M0 R13 300 M1 R19 200 M2+ R25 800 |
OVER THE COUNTER MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R1 990 per beneficiary |
LASER K/EXCIMER LASER | 80% CBT limited to R5 005 per beneficiary per eye |
SPECTACLES AND LENSES | Consultation: See Preventative Wellness Benefit Add ons R1 150 Single vision R1 150 OR Bifocal R3 080 OR Varifocal R4 730 AND Frames R4 250 OR Contact lenses R4 130 Lenses, frames etc 80% Optical Assistant Rates |
Monthly Risk Contribution | Adult Child | R4 050 R2 320 |
Monthly MSA Contribution | Adult Child | R 392 R 252 |
Total Monthly Contribution | Adult Child | R4 442 R2 572 |
Any Private Hospital: No limits | |
Attending Doctors and Specialists: Up to 300% of CBT | |
63 Chronic Conditions: Medication and consultations. Covers the medication and necessary consultations and procedures. Includes unlimited appropriate biological drugs and specialised technology as well as door to door medication delivery | |
Unlimited X-Rays and Blood Tests IN and OUT of hospital including MRI’s and CT’s | |
Screening Benefits | |
3 Month post hospitalisation benefit | |
External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor | |
Check-Ups and Vaccines: GP, Specialist, Dental, Optometry, ECG |
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 | 100% of Negotiated Rate in general ward and specialised units |
ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS | Up to 300% CBT 300% CBT |
SUPPLEMENTARY HEALTHCARE IN HOSPITAL | 100% CBT |
BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
RADIOLOGY IN HOSPITAL | 100% CBT 100% CBT |
PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost |
HOME NURSING | 100% CBT |
STEP-DOWN/PHYSICAL REHABILITATION APPROVED | 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 | 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - as per PMB regulations |
PMB DTP TREATMENT | Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - as per PMB regulations |
ONCOLOGY | Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - at 300% CBT The ICON Core benefits apply |
#Please refer to website for ICON benefit structures
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
PREVENTATIVE WELLNESS COVER | |
---|---|
CAMAF PREVENTATIVE PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R13 040 per beneficiary |
ONE DIETICIAN CONSULTATION | 100% CBT per beneficiary |
ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY - excludes consumables | 100% CBT per beneficiary |
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, limited to R1 852 per beneficiary |
CERVICAL CANCER VACCINE (HPV) | Females between 9 and 16 years of age (SEP plus dispensing fee) |
ONE HIV VCT TEST | 100% CBT per beneficiary |
MELANOMA SCREENING | 100% CBT per adult beneficiary |
*Refer to website for relevant ICD 10 codes.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
MATERNITY BENEFITS | |
---|---|
HOSPITAL ACCOMMODATION | See In Hospital and Prescribed Minimum Benefits above |
EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES | Baby Apnoea Monitors: R2 780 Breast pumps: R4 630 |
METABOLIC SCREENING FOR NEW BORN BABIES | 100% Negotiated Rate per new born baby |
UMBLICAL STEM CELL HARVESTING | Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits. |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
BASIC AND ADVANCED RADIOLOGY | 100% CBT |
PATHOLOGY | 100% Negotiated Rate or CBT |
POST-HOSPITALISATION | 300% CBT for attending practitioners 100% CBT for supplementary services |
MEDICATION FOR ADDITIONAL | 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT |
EXTERNAL APPLIANCES (subject to referral) | 100% NAPPI price or 100% of cost, subject to the overall limit of R41 600 per beneficiary and subject to the following sub-limits: Hearing Aids: R36 150 Wheelchairs for Quadriplegics: R36 150 Standard Wheelchairs: R25 400 Insulin Pumps: R41 600 Other external appliances: R 9 060 |
INTERNATIONAL TRAVEL COVER | 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 | Unlimited Subject to Netcare 911 authorisation |
Monthly income based on Total Cost to Company of Principal Member | Total Monthly Contribution | |
---|---|---|
R0 - R46 120 | Adult Child | R2 375 R1 218 |
R46 121 – R115 310 | Adult Child | R2 693 R1 374 |
R115 311+ | Adult Child | R2 987 R1 530 |
Any Private Hospital: No limits | |
Attending Doctors and Specialists: Up to 200% of CBT | |
27 Chronic Conditions: Medication and consultations | |
Unlimited X-Rays and Blood Tests IN hospital including MRI and CT scans | |
Screening Benefits | |
Check-ups and Immunisation Benefits |
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, | 100% of Negotiated Rate in general ward and specialised units |
ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS | Up to 200% CBT 200% CBT |
SUPPLEMENTARY HEALTHCARE IN HOSPITAL | 100% CBT |
BLOOD TRANSFUSIONS | 100% of cost |
RADIOLOGY IN HOSPITAL | 100% CBT 100% CBT |
PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost Exclusions: cochlear implants |
HOME NURSING | 100% CBT |
STEP-DOWN/PHYSICAL REHABILITATION APPROVED | 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 | 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - as per PMB regulations |
PMB DTP TREATMENT | Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - as per PMB regulations |
ONCOLOGY | Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - 100% DSP Tariff The DSP is the ICON network The ICON Essential benefits apply |
#Please refer to website for ICON benefit structures
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
PREVENTATIVE WELLNESS COVER | |
---|---|
CAMAF PREVENTATIVE PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R13 040 per beneficiary |
ONE DIETICIAN CONSULTATION | 100% CBT per beneficiary |
ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY - excludes consumables | 100% CBT per beneficiary |
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) | 100% CBT per beneficiary |
ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, limited to R1 852 per beneficiary |
CERVICAL CANCER VACCINE (HPV) | Females between 9 and 16 years of age (SEP plus dispensing fee) |
ONE HIV VCT TEST | 100% CBT per beneficiary |
MELANOMA SCREENING | 100% CBT per adult beneficiary |
*Refer to website for relevant ICD 10 codes.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
MATERNITY BENEFITS | |
---|---|
HOSPITAL ACCOMMODATION | See In Hospital and Prescribed Minimum Benefits |
EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES | 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. |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
BASIC AND ADVANCED RADIOLOGY | Subject to Medical Savings Account |
PATHOLOGY | Subject to Medical Savings Account |
POST-HOSPITALISATION | Subject to Medical Savings Account |
MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS | Depression only. 100% SEP plus a dispensing fee subject to RP and DSP Consultations 100% CBT |
EXTERNAL APPLIANCES (subject to referral) | Subject to Medical Savings Account |
INTERNATIONAL TRAVEL COVER | 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 | Unlimited Subject to Netcare 911 authorisation |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
DAY TO DAY BENEFITS | Limited to funds available in the beneficiary’s Medical Savings Account |
GP's AND DENTISTS | Subject to Medical Savings Account |
SPECIALISTS | Subject to Medical Savings Account |
ACUTE MEDICATION | 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 | Subject to Medical Savings Account |
BENEFIT SPECIFIC LIMITS |
|
ADVANCED DENTISTRY | Subject to Medical Savings Account |
OVER THE COUNTER MEDICATION | Subject to Medical Savings Account |
LASER K/EXCIMER LASER | Subject to Medical Savings Account |
SPECTACLES AND LENSES | Subject to Medical Savings Account |
Monthly income based on Total Cost to Company of Principal Member | Total Monthly Contribution | |
---|---|---|
R0 - R115 310 | Principal Adult Child | R1 951 R1 542 R 906 |
Monthly MSA Contribution | Principal Adult Child | R 590 R 470 R 280 |
Total Monthly Contribution | Principal Adult Child | R2 541 R2 012 R1 186 |
R115 311+ | Principal Adult Child | R2 344 R1 858 R1 087 |
Monthly MSA Contribution | Principal Adult Child | R 590 R 470 R 280 |
Total Monthly Contribution | Principal Adult Child | R2 934 R2 328 R1 367 |
Any Private Hospital: No limits | |
Attending Dr’s and Specialists: Up to 100% CBT | |
27 Chronic Conditions: medication and consultations. Includes unlimited appropriate biological drugs and specialised technology and door to door medication delivery |
|
X-Rays and Blood Tests Advanced scans limited to R38 000 per family | |
Screening Benefits | |
80% of GP, Specialists, Dental, Optometry, Check-ups, ECG, Vaccines |
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, | 100% of Negotiated Rate in general ward and specialised units |
ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS | Up to 100% CBT 100% CBT |
SUPPLEMENTARY HEALTHCARE IN HOSPITAL | 100% CBT |
BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
RADIOLOGY IN HOSPITAL | 100% CBT 100% CBT limited to R38 000 per family |
PATHOLOGY IN HOSPITAL | 100% CBT |
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost limited to R38 000 per family Exclusions: cochlear implants |
HOME NURSING | 100% CBT (in lieu of hospitalisation only) |
STEP-DOWN/PHYSICAL REHABILITATION APPROVED | 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 | 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - as per PMB regulations |
PMB DTP TREATMENT | Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - as per PMB regulations |
ONCOLOGY | Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - 100% DSP Tariff The DSP is the ICON network The ICON Essential benefits apply |
#Please refer to website for ICON benefit structures.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
PREVENTATIVE WELLNESS COVER | |
---|---|
CAMAF PREVENTATIVE PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R13 040 per beneficiary |
ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY - excludes consumables | 100% CBT per beneficiary |
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | Refer to spectacle and lenses benefits |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, subject to MMAP, limited to R1 852 per beneficiary |
CERVICAL CANCER VACCINE (HPV) | Females between 9 and 16 years of age (SEP plus dispensing fee) |
ONE HIV VCT TEST | 100% CBT per beneficiary |
*Refer to website for relevant ICD 10 codes.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
MATERNITY BENEFITS | |
---|---|
HOSPITAL ACCOMMODATION | See In Hospital and Prescribed Minimum Benefits |
EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES LIMIT | Baby Apnoea Monitors: R2 265 Breast pumps: R3 900 |
METABOLIC SCREENING FOR NEW BORN BABIES | 100% Negotiated Rate per new born baby |
ANTE-NATAL FOETAL SCANS PER PREGNANCY | 3 scans at 80% CBT. Subject to limit (c) of Annual Overall Day-to-Day Benefit Limit |
ANTE-NATAL CLASSES | 80% CBT subjects to sub-limit R1 050 per pregnancy. Subject to limit (c) of Annual Overall Day-to-Day Benefit Limit |
UMBLICAL STEM CELL HARVESTING | Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits. |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
BASIC AND ADVANCED RADIOLOGY | Basic Radiology: 100% CBT limited to R4 440 per beneficiary Advanced scans: 100% CBT limited to R38 000 per family |
PATHOLOGY | 100% Negotiated Rate limited to R7 090 per beneficiary |
MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS | Depression only. 100% SEP plus a dispensing fee subject to RP and DSP Consultations 100% CBT |
EXTERNAL APPLIANCES (subject to referral) | 100% NAPPI price or 100% of cost, in hospital and 80% of cost out of hospital with an overall limit of R6 790 per beneficiary |
INTERNATIONAL TRAVEL COVER | 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 | Unlimited Subject to Netcare 911 authorisation |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
DAY TO DAY BENEFITS | Annual overall limit: Beneficiary specific limits: (a) Medicines R3 290 (b) Advanced Dentistry R6 890 (c) Other R3 290 (d) Specialists R10 120 |
GP's AND DENTISTS | 80% CBT Subject to limit (c) |
SPECIALISTS | 80% CBT Subject to limit (d) |
ACUTE MEDICATION | 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 | 80% CBT subject to sub-limit R2 760 Subject to limit (c) |
BENEFIT SPECIFIC LIMITS |
|
ADVANCED DENTISTRY | 50% CBT Subject to limit (b) dental implants excluded |
OVER THE COUNTER MEDICATION | 50% SEP plus a dispensing fee, subject to MMAP, limited to R1 690 per beneficiary. Subject to limit (a) |
SPECTACLES AND LENSES | The benefit PER BENEFICIARY at a PPN provider would be as follows: For the benefit cycle of 24 months from date of claiming, each beneficiary is entitled to: One Composite Consultation inclusive of a Refraction, Tonometry and Visual Field screening AND EITHER SPECTACLES - A PPN Frame to the value of R150 or R750 off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear A quity Single Vision; Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R840. The benefit PER BENEFICIARY at a NON PPN provider would be as follows: One consultation per Beneficiary during the Benefit Cycle, limited to a maximum cost of R300 AND EITHER SPECTACLES - A frame benefit of R600 towards the cost of a frame and/or lens enhancements and one pair of lenses: either one pair of clear single vision spectacle lenses limited to R175 per lens or one pair of clear flat top bifocal spectacle lenses limited to R410 per lens or one pair of clear flat top Multifocal lenses limited to R710 per lens OR CONTACT LENSES - Contact Lenses to the value of R840. |
Monthly income based on Total Cost to Company of Principal Member | Total Monthly Contribution | |
---|---|---|
R0 - R9 830 | Adult Child | R1 171 R 713 |
R9 831 - R18 960 | Adult Child | R1 859 R1 101 |
R18 961 - R25 420 | Adult Child | R2 791 R1 623 |
R25 421 - R38 140 | Adult Child | R3 473 R2 284 |
R38 141+ | Adult Child | R3 798 R2 479 |
Network Hospital: No limits (DSP hospital group is Netcare) | |
Attending Doctors: Up to 100% CBT only at DSP | |
27 Chronic Conditions: medication and consultations. Includes unlimited appropriate biological drugs and specialised technology and door to door medication delivery |
|
X-Rays and Blood Tests Advanced scans limited to R38 000 per family | |
Screening Benefits | |
Vaccines |
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, | 100% DSP tariff as per protocols. The DSP hospital group is Netcare. |
ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS | Up to 100% CBT 100% CBT |
SUPPLEMENTARY HEALTHCARE IN HOSPITAL | 100% CBT |
BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
RADIOLOGY IN HOSPITAL | 100% CBT 100% CBT limited to R38 000 per family |
PATHOLOGY IN HOSPITAL | 100% CBT |
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost limited to R38 000 per family Exclusions: cochlear implants |
HOME NURSING | 100% CBT (in lieu of hospitalisation only) |
STEP-DOWN/PHYSICAL REHABILITATION APPROVED | 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 - | 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - as per PMB regulations |
PMB DTP TREATMENT | Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - as per PMB regulations |
ONCOLOGY | Medication - 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures - 100% DSP Tariff The DSP is the ICON network The ICON Essential benefits apply |
#Please refer to website for ICON benefit structures
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
PREVENTATIVE WELLNESS COVER | |
---|---|
CAMAF PREVENTATIVE PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary (Network Doctor only) |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R13 040 per beneficiary |
ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY - excludes consumables | 100% CBT per beneficiary |
ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | Refer to spectacle and lenses benefits |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, subject to MMAP, limited to R1 852 per beneficiary |
CERVICAL CANCER VACCINE (HPV) | Females between 9 and 16 years of age (SEP plus dispensing fee) |
ONE HIV VCT TEST | 100% CBT per beneficiary |
*Refer to website for relevant ICD 10 codes.
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
MATERNITY BENEFITS | |
---|---|
HOSPITAL ACCOMMODATION | See In Hospital and Prescribed Minimum Benefits |
EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES | Baby Apnoea Monitors: R2 265 Breast pumps: R3 900 |
METABOLIC SCREENING FOR NEW BORN BABIES | 100% Negotiated Rate per new born baby |
ANTE-NATAL FOETAL SCANS PER PREGNANCY | 3 scans at 80% CBT. Subject to limit (c) of Annual Overall Day-to-Day Benefit Limit |
ANTE-NATAL CLASSES | 80% CBT subjects to sub-limit R1 050 per pregnancy. Subject to limit (c) of Annual Overall Day-to-Day Benefit Limit |
UMBLICAL STEM CELL HARVESTING | Negotiated discount with Cryo-Save. Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition. The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits. |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
BASIC AND ADVANCED RADIOLOGY | Basic Radiology: Referrals by DSP or specialist, 100% CBT limited to R4 440 per beneficiary Advanced scans: 100% CBT limited to R38 000 per family (on referral by DSP or specialist) |
PATHOLOGY | Referred by DSP or specialist, 100% Negotiated Rate, limited to R7 090 per beneficiary |
MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS | Depression only. 100% SEP plus a dispensing fee subject to RP and DSP Consultations 100% CBT |
EXTERNAL APPLIANCES (subject to referral) | 100% NAPPI price or 100% of cost, limited to R6 790 per beneficiary and subject to DSP or Specialist referral |
INTERNATIONAL TRAVEL COVER | 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 | Unlimited Subject to Netcare 911 |
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
---|---|
DAY TO DAY BENEFITS | Annual overall limit: Beneficiary specific limits: (a) Medicines R3 290 (b) Advanced Dentistry R6 890 (c) Other R3 290 (d) Specialists R10 120 |
GP's AND DENTISTS | 100% negotiated rate subject to sublimit (c) - Network GP only |
SPECIALISTS | 100% CBT Subject to limit (d) (on referral from a network GP only) |
ACUTE MEDICATION | 100% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a) (on referral from a network GP only) |
NON-DSP VISITS | One non-network visit per beneficiary or two per family, 20% co-payment |
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL | One casualty visit per family (facility fee, consumed meds and materials). Limited to R 1 417 |
NURSE VISITS | 100% CBT subject to limit (c) |
SUPPLEMENTARY HEALTH | 100% CBT limited to R2 760 per beneficiary on referral from DSP or from a Specialist. Subject to limit (c) |
BENEFIT SPECIFIC LIMITS |
|
ADVANCED DENTISTRY | 100% of CBT Subject to limit (b) dental implants excluded |
OVER THE COUNTER MEDICATION | 50% SEP plus a dispensing fee, subject to MMAP, limited to R1 690 per beneficiary. Subject to limit (a) |
SPECTACLES AND LENSES | The benefit PER BENEFICIARY at a PPN provider would be as follows: For the benefit cycle of 24 months from date of claiming, each beneficiary is entitled to: One Composite Consultation inclusive of a Refraction, Tonometry and Visual Field screening AND EITHER SPECTACLES - A PPN Frame to the value of R150 or R750 off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear A quity Single Vision; Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R840. The benefit PER BENEFICIARY at a NON PPN provider would be as follows: One consultation per Beneficiary during the Benefit Cycle, limited to a maximum cost of R300 AND EITHER SPECTACLES - A frame benefit of R600 towards the cost of a frame and/or lens enhancements and one pair of lenses: either one pair of clear single vision spectacl e lenses limited to R175 per lens or one pair of clear flat top bifocal spectacle lenses limited to R410 per lens or one pair of clear flat top Multifocal lenses limited to R710 per lens OR CONTACT LENSES - Contact Lenses to the value of R840. |
Monthly income based on Total Cost to Company of Principal Member | Total Monthly Contribution | |
---|---|---|
R0 - R18 960 | Principal Adult 1st Child (rest are free) | R1 667 R1 394 R 725 |
R18 961 - R25 420 | Principal Adult 1st Child (rest are free) | R1 982 R1 582 R 891 |
R25 421 - R38 140 | Principal Adult 1st Child | R2 372 R1 837 R1 182 |
R38 141+ | Principal Adult 1st Child | R3 153 R2 544 R1 548 |
Monthly Risk Contribution Adult R6 116 Child R3 325 Monthly MSA Contribution Adult R 610 Child R 280 Total Monthly Contribution Adult R6 726 Child R3 605 | Monthly Risk Contribution Adult R4 050 Child R2 320 Monthly MSA Contribution Adult R 392 Child R 252 Total Monthly Contribution Adult R4 442 Child R2 572 | Monthly income based on Total Cost to Company of Principal Member Total Monthly Contribution R 0 - R46 120 Adult R2 375 Child R1 218 R46 121 - R115 310 Adult R2 693 Child R1 374 R115 311+ Adult R2 987 Child R1 530 | Monthly income based on Total Cost to Company of Principal Member Total Monthly Contribution R 0 - R115 310 Principal R1 951 Adult R1 542 Child R 906 Monthly MSA Contribution Principal R 590 Adult R 470 Child R 280 Total Monthly Contribution Principal R2 541 Adult R2 012 Child R1 186 R115 311+ Principal R2 344 Adult R1 858 Child R1 087 Monthly MSA Contribution Principal R 590 Adult R 470 Child R 280 Total Monthly Contribution Principal R2 934 Adult R2 328 Child R1 367 | Monthly income based on Total Cost to Company of Principal Member Total Monthly Contribution R0 - R9 830 Adult R1 171 Child R 713 R9 831 - R18 960 Adult R1 859 Child R1 101 R18 961 - R25 420 Adult R2 791 Child R1 623 R25 421 - R38 140 Adult R3 473 Child R2 284 R38 141+ Adult R3 798 Child R2 479 | Monthly income based on Total Cost to Company of Principal Member Total Monthly Contribution R 0 - R18 960 Principal R1 667 Adult R1 394 1st Child R 725 (rest are free) R18 961- R25 420 Principal R1 982 Adult R1 582 1st Child R 891 (rest are free) R25 421 - R38 140 Principal R2 372 Adult R1 837 Child R1 182 R38 141+ Principal R3 153 Adult R2 544 Child R1 548 |
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.
Condition | Consultations | Level of Consultation Cover |
---|---|---|
ADHD (Alliance Plus & Alliance Network only) | Paediatrician, Neurologist, Psychiatrist | 100% CBT |
ALLERGIC RHINITIS | GP, Ear Nose and Throat Specialist (ENT), Paediatrician | 100% CBT |
ALZHEIMER’S DISEASE | Neurologist, Psychiatrist | 100% CBT |
ANKYLOSING SPONDYLITIS | Physician, Rheumatologist | 100% CBT |
BENIGN PROSTATIC HYPERTROPHY | Urologist | 100% CBT |
CHRONIC GRANULOMATOUS DISEASE | Physician | 100% CBT |
COAGULATION DISORDERS | Cardiologist, Physician, Clinical Haemotologist | 100% CBT |
CONGENITAL HEART MALFORMATIONS | Physician, Cardiologist, Paediatrician | 100% CBT |
CYSTIC FIBROSIS | Physician, Physiotherapist, Pulmonologist, Paediatrician, GP | 100% CBT |
DEEP VEIN THROMBOSIS | Physician | 100% CBT |
DEPRESSION (includes First Choice, Essential Plus and Essential Network) | GP, Psychiatrist, Clinical Psychologist, Social Worker | 100% CBT |
ECZEMA | Dermatologist, GP | 100% CBT |
ENDOMETRIOSIS | Gynaecologist | 100% CBT |
GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD) | GP, Gastroenterologist, Physician, Paediatrician | 100% CBT |
GAUCHERS DISEASE | Physician, Paediatrician | 100% CBT |
GOUT PROPHYLAXIS | GP | 100% CBT |
HORMONE REPLACEMENT | GP | 100% CBT |
HYPERPARATHYROIDISM | Physician | 100% CBT |
HYPERTHYROIDISM | GP, Paediatrician | 100% CBT |
MENIERE’S DISEASE | GP, Ear Nose and Throat Specialist (ENT) | 100% CBT |
MIGRAINE PROPHYLAXIS | GP, Neurologist | 100% CBT |
MUSCULAR DYSTROPHY | Neurologist, Physician, Paediatrician | 100% CBT |
MYASTHENIA GRAVIS | Physician | 100% CBT |
NARCOLEPSY | Neurologist | 100% CBT |
ORGAN TRANSPLANT | Appropriate multi disciplinary team | 100% CBT |
OSTEOARTHRITIS | Physician, Rheumatologist, GP | 100% CBT |
OSTEOPOROSIS | Physician, Gynaecologist, GP | 100% CBT |
PLEGIA; HEMI, PARA & QUAD | Physician, Orthopaedic Surgeon, Physiotherapist, Urologist, Neurologist, Occupational Therapist, Paediatrician, Speech Therapist, GP | 100% CBT |
POLYCYSTIC OVARIAN SYNDROME | Gynaecologist | 100% CBT |
PSORIASIS | Dermatologist | 100% CBT |
RESTRICTIVE LUNG DISEASE | Pulmonologist, Physician | 100% CBT |
TRANSIENT ISCHAEMIC ATTACK / STROKE | Physician, Neurologist | 100% CBT |
TUBERCULOSIS | GP | 100% CBT |
VALVULAR HEART DISEASE | Physician, Cardiologist, Paediatrician | 100% CBT |
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 |
*More details available on the website www.camaf.co.za
– for full explanations, consult the Registered Rules
ADULT | Refers to the member and dependants who are 22 or older at any time in the year of cover. |
CBT | CAMAF Base Tariff - the maximum rate paid by the Scheme to providers of healthcare services, based on 2009 RPL (Medical Aid) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options. |
CDL | Chronic Disease List - the list of PMB’s includes 25 common chronic conditions called CDL’s. Schemes must provide cover for the diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s). |
CML/ FORMULARY | Condition Medicine List - once a patient’s chronic condition has been registered, a patient will have access to the CML. This is a list of drugs, appropriate for the condition, that do not require authorisation. This is maintained by the Scheme and differs per Option. Reference pricing may still apply. |
CHILD | Refers to a dependant who is younger than an adult, as defined above. |
DISPENSING FEES | Fee negotiated by the Scheme with Network pharmacies and added to SEP. |
DSP | The network of service providers contracted to provide healthcare services to members, eg. Independent Clinical Oncology Network (ICON), HIV programme (LifeSense), PPN for optical benefits, Pharmacy networks for all chronic medications, Netcare 911 for emergency transport and Netcare hospital group for Network Choice hospital admissions. |
DTP | The Regulations to the Medical Schemes Act in Annexure A provide a list of conditions identified as Prescribed Minimum Benefits. The List is in the form of Diagnosis Treatment Pairs (DTP’s). A DTP links a specific diagnosis to a treatment/procedure and therefore broadly indicates how each of the 270 PMB conditions should be treated. These treatment pairs cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s). |
ICD 10 CODE | Stands for International Classification of Diseases and Related Health Problems (10th revision). It is a coding system developed by the World Health Organisation (WHO) that translates the written description of medical and health information into standard codes, e.g. J03.9 is an ICD-10 code for acute tonsillitis (unspecified) and G40.9 denotes epilepsy (unspecified). These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be paid from the correct benefit. |
INCOME | Total cost to company prior to deductions. |
MEDICAL SAVINGS ACCOUNT (MSA) | A savings account that accrues monthly but the annualised amount of savings is available immediately and can be used for: • top up on cost of service charged by a doctor • extension when an overall benefit has been exceeded • exclusion from benefits • payment of day to day claims on Essential Plus option |
METABOLIC SCREENING | Newborn screening whereby rare disorders are detected by a blood test done 48 - 72 hours after birth. |
MMAP | Maximum Medical Aid Price - is a reference price model and determines the maximum medical scheme price that medical schemes will reimburse for an interchangeable multi-source pharmaceutical product (generic) on the relevant option. MMAP applies to all options for chronic medication. |
NEGOTIATED RATE | This is the rate, negotiated by the scheme with the service provider/group of service providers, eg. hospitals and pathologists. |
PMB | Prescribed Minimum Benefits - as set out in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the diagnosis, treatment and care of: • Any emergency medical condition • A limited set of 270 medical conditions (Defined in DTP’s) • 25 chronic conditions defined in the CDL • These costs may not be paid from the member’s savings benefit and cost saving measures can be used by way of utilising DSP’s, Reference Pricing and Formularies. |
PRE-AUTHORISATION | A member must obtain prior approval for an intended admission to hospital. Failure to pre-authorise could result in wholly or partly disallowing the claim or imposing a penalty of 20% of related accounts up to a maximum of R 2 500. Emergency treatment is not subject to Pre-authorisation but members should notify the Scheme as soon as possible after the event. |
PROTOCOL | Means a set of guidelines in relation to diagnostic testing and management of specific conditions and includes, but is not limited to, clinical practice guidelines, standard treatment guidelines and disease management guidelines. |
RISK CONTRIBUTIONS | Those funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account. |
RP | Reference Pricing is the maximum price for which the Scheme will be liable for specific medicine or classes of medicine, listed on the Scheme’s Condition Medicine List (CML). The reference price varies per option and where a drug is above the reference price it is indicated that a co-payment will apply. This includes MMAP. |
SEP | Single Exit Price - nationally applied pricing for medication as determined by the Department of Health and the pharmaceutical manufacturers. |
TTO | “To Take Out” - medication supplied by the hospital for use after the date of discharge from hospital - limited to a 7 day supply. |