CAMAF Benefit Brochure 2024

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

Please note that all 2024 Benefit Option information, benefits and limits are subject to Council for Medical Schemes (CMS) approval.

CAMAF BENEFIT OPTION 2024 – PDF DOWNLOAD

CAMAF Benefit Option Summary

CAMAF Benefit Options: Quick Summary

Alliance Plus
Alliance Network
Double Plus
Double Network
Vital Plus
Vital Network
Essential Plus
Essential Network
First ChoiceNetwork Choice
Hospital FacilityAlliance Plus
Any private hospital. Private wards for childbirth confinements (subject to availability).

Alliance Network
Life Healthcare, Netcare. Private wards for childbirth 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 hospitalNetcare hospitals only
Cover For Attending Doctors
and Specialists In Hospital
300% CBT300% CBT300% CBT200% CBT100% CBT100% 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 PathologyUnlimited In or Out of HospitalUnlimited In or Out of HospitalUnlimited In or Out of HospitalUnlimited In Hospital,
Out of Hospital from MSA
Limits apply In and Out of HospitalLimits apply In and Out of Hospital
Preventive Wellness Benefits14 extra benefits14 extra benefits14 extra benefits14 extra benefits11 extra benefits11 extra benefits
Day To Day Overall LimitR41 870R16 313-R3 922 for medicines.
R12 070 for specialists.
R3 922 for other.
Paid at 80%
R3 922 for medicines.
R12 070 for specialists.
R3 922 for other.
From DSP only
Medical Savings Account
(Principal Member)
Alliance Plus:
R7 500

Alliance Network:
R6 780
Double Plus:
R4 800

Double Network:
R4 440
-Essential Plus:
R8 400

Essential Network:
R7 560
--

Benefit Option: Alliance Plus & Alliance Network

Alliance Plus: Any Private Hospital – No limits. Private wards for childbirth 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 childbirth 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 R106 811 per family
A-PLUS
A-Network

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 CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION

100% of Negotiated Rate in general ward and specialised units. Private ward for childbirth 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 CHILDBIRTH 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 R106 811 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.

A-PLUS
A-Network

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.

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 R16 274 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 547 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.

A-PLUS
A-Network

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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
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 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 372
Breast pumps: R5 517

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 227 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.
A-PLUS
A-Network

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.

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) - 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 (subject to pre-authorisation and DSP) - 4 YEAR CYCLE

100% NAPPI price or 100% of cost, subject to the overall limit of R107 829 per beneficiary and subject to the following sub-limits:
Hearing Aids: R107 829
Wheelchairs for Quadriplegics: R107 829
Standard Wheelchairs: R64 337
Insulin Pumps: R64 337
Other external appliances: R21 348
(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 you have declared your trip 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. Refer to Travel Letter Wording.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation
A-PLUS
A-Network

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.

OTHER BENEFITS (per Beneficiary)

DAY TO DAY BENEFITS
BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT

Annual Overall Limits
Adult R41 870
Child R26 076

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 R21 348
M1 R31 906
M2+ R38 478

OVER THE COUNTER MEDICATION

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R5 269 per beneficiary

LASER K/EXCIMER LASER
NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS

80% CBT limited to R16 165 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

PPN is the DSP for Alliance Network
Consultation: See Preventive Wellness Benefit
Add-ons R2 094
Single vision R2 094 OR
Bifocal R4 198 OR
Varifocal R6 318 AND
Frames R9 423 OR
Contact lenses R9 158
Lenses, frames etc 80% Optical Assistant Rates
A-PLUS
A-Network

ALLIANCE PLUS & ALLIANCE NETWORK

MONTHLY CONTRIBUTION RATES
Alliance PlusAlliance Network
Monthly Risk ContributionAdult
Child
R7 825
R4 232
R7 093
R3 835
Monthly MSA ContributionAdult
Child
R   625
R   290
R   565
R   260
Total Monthly ContributionAdult
Child
R8 450
R4 522
R7 658
R4 095

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 R75 329 per family
D-PLUS
D-Network

DOUBLE PLUS & DOUBLE 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 CHILDBIRTH 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 CHILDBIRTH 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 R75 329 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.

D-PLUS
D-Network

DOUBLE PLUS & DOUBLE 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.

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 R16 274 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 287
Child R5 438

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.

D-PLUS
D-Network

DOUBLE PLUS & DOUBLE 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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
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 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 313
Breast pumps: R5 517

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 366 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.
D-PLUS
D-Network

DOUBLE PLUS & DOUBLE 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.

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) - 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 (subject to pre-authorisation and DSP) - 4 YEAR CYCLE

100% NAPPI price or 100% of cost, subject to the overall limit of R86 203 per beneficiary and subject to the following sub-limits:
Hearing Aids: R86 203
Wheelchairs for Quadriplegics: R86 203
Standard Wheelchairs: R54 982
Insulin Pumps: R56 297
Other external appliances: R18 486

(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 you have declared your trip 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. Refer to Travel Letter Wording.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation
D-PLUS
D-Network

DOUBLE PLUS & DOUBLE 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.

OTHER BENEFITS (per Beneficiary)

DAY TO DAY BENEFITS
BENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT

Annual Overall Limits
Adult R16 313
Child R11 321

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 900
M1 R22 896
M2+ R30 835

OVER THE COUNTER MEDICATION

80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R2 337 per beneficiary

LASER K/EXCIMER LASER
NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS

80% CBT limited to R5 968 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

PPN is the DSP for Double Network
Consultation: See Preventive Wellness Benefit
Add ons R1 378
Single vision R1 378
OR
Bifocal R3 678
OR
Varifocal R5 639
AND
Frames R5 067
OR
Contact lenses R4 918
Lenses, frames etc 80% Optical Assistant Rates
D-PLUS
D-Network

DOUBLE PLUS & DOUBLE NETWORK

MONTHLY CONTRIBUTION RATES
Double PlusDouble Plus
Monthly Risk ContributionAdult
Child
R5 172
R2 965
R4 710
R2 691
Monthly MSA ContributionAdult
Child
R   400
R   260
R   370
R   240
Total Monthly ContributionAdult
Child
R5 572
R3 225
R5 080
R2 931

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
V-PLUS
V-Network

VITAL PLUS & VITAL 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 CHILDBIRTH 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 CHILDBIRTH 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

V-PLUS
V-Network

VITAL PLUS & VITAL 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.

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 R16 274 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 178 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.

V-PLUS
V-Network

VITAL PLUS & VITAL 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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
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 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 307
Breast pumps: R5 517

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.
V-PLUS
V-Network

VITAL PLUS & VITAL 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.

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) - 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 (subject to pre-authorisation and DSP) - 4 YEAR CYCLE

100% NAPPI price or 100% of cost, subject to the overall limit of R49 613 per beneficiary and subject to the following sub-limits:
Hearing Aids: R43 110
Wheelchairs for Quadriplegics: R43 116
Standard Wheelchairs: R30 279
Insulin Pumps: R49 613
Other external appliances: R10 807

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 you have declared your trip 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. Refer to Travel Letter Wording.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation
V-PLUS
V-Network

VITAL PLUS & VITAL 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.

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 VISITS
TO 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

WHERE PPN IS INDICATED AS THE DSP, THE PPN RATES AND TARIFFS WILL APPLY. FOR ALL OTHER OPTIONS, OPTICAL ASSISTANT RATES WILL APPLY

Consultation: Part of Preventive Wellness
V-PLUS
V-Network

VITAL PLUS & VITAL NETWORK

MONTHLY CONTRIBUTION RATES
Vital PlusVital Network
Monthly income based on Total Cost to Company of Principal MemberTotal Monthly Contribution
R0 - R54 510Adult
Child
R2 955
R1 515
R2 750
R1 410
R54 511 – R136 270Adult
Child
R3 350
R1 710
R3 120
R1 590
R136 271+Adult
Child
R3 725
R1 910
R3 470
R1 775

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 Vaccines: GP, Specialist, Dental, Optometry, ECG
E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL 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 CHILDBIRTH 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 CHILDBIRTH 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

E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL 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.

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 R16 274 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 308 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.

E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL 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.

MATERNITY BENEFITS

HOSPITAL ACCOMMODATION
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 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.
E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL 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.

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) - 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

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 you have declared your trip 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. Refer to Travel Letter Wording.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation
E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL 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.

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
E-PLUS
E-Network

ESSENTIAL PLUS & ESSENTIAL NETWORK

MONTHLY CONTRIBUTION RATES
Essential PlusEssential Network
Monthly income based on Total Cost to Company of Principal MemberTotal Monthly Contribution
R0 - R136 270
Monthly Risk ContributionPrincipal
Adult
Child
R2 450
R1 935
R1 140
R2 210
R1 745
R1 025
Monthly MSA ContributionPrincipal
Adult
Child
R 700
R 560
R 330
R 630
R 500
R 300
Total Monthly ContributionPrincipal
Adult
Child
R3 150
R2 495
R1 470
R2 840
R2 245
R1 325
R136 271+
Monthly Risk ContributionPrincipal
Adult
Child
R2 950
R2 335
R1 370
R2 660
R2 110
R1 235
Monthly MSA ContributionPrincipal
Adult
Child
R 700
R 560
R 330
R 630
R 500
R 300
Total Monthly ContributionPrincipal
Adult
Child
R3 650
R2 895
R1 700
R3 290
R2 610
R1 535

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
Radiology Advanced scans limited to R45 320 per family and R5 300 per beneficiary for basic radiology
Screening Benefits: PSA, Pap Smear, Mammogram
80% of GP, Specialists, Dental, Optometry, Checkups, ECG, Vaccines

FIRST CHOICE

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 CHILDBIRTH 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 CHILDBIRTH 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 R45 320 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 R45 320 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

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.

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 R16 274 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 213 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

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
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 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 703
Breast pumps: R4 648

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 246 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

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
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 300 per beneficiary
Advanced scans: 100% CBT limited to R45 320 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 R8 460 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) - 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 R8 093 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 you have declared your trip 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. Refer to Travel Letter Wording.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation

FIRST CHOICE

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)

DAY TO DAY BENEFITS
BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT

Annual overall limit: Beneficiary specific limits:
(a) Medicines R3 922
(b) Advanced Dentistry R8 220
(c) Other R3 922
(d) Specialists R12 070

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
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 300
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 R2 014 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 R850 off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear Aquity Single Vision; Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R925.

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 R380 AND EITHER SPECTACLES - A frame benefit of R850 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 R925.

FIRST CHOICE

MONTHLY CONTRIBUTION RATES
First Choice
Monthly income based on Total Cost to Company of Principal MemberTotal Monthly Contribution
R0 - R11 620Adult
Child
R1 455
R   885
R11 621 - R22 410Adult
Child
R2 310
R1 370
R22 411 - R30 040Adult
Child
R3 470
R2 020
R30 041 - R45 070Adult
Child
R4 360
R2 870
R45 071+Adult
Child
R4 770
R3 115

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
Radiology Advanced scans limited to R45 320 per family and R5 300 per beneficiary for basic radiology (on referral by nominated GP or specialist for out of hospital)
Screening Benefits: PSA, Pap Smear, Mammogram
Vaccines

NETWORK CHOICE

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 CHILDBIRTH 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 CHILDBIRTH 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 R45 320 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 R45 320 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

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.

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 R16 274 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 213 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

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
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 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 703
Breast pumps: R4 648

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 246 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

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
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 300 per beneficiary
Advanced scans: 100% CBT limited to R45 320 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 R8 460 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) - 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 R8 093 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 you have declared your trip 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. Refer to Travel Letter Wording.

NETCARE 911
EMERGENCY SERVICES

Unlimited
Subject to Netcare 911 authorisation

NETWORK CHOICE

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
BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT

Annual overall limit: Beneficiary specific limits:
(a) Medicines R3 922
(b) Advanced Dentistry R8 220
(c) Other R3 922
(d) Specialists R12 070

GPs 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 675.

One non-network or non-nominated visit per beneficiary or two per family, 20% co-payment AND One casualty visit per family (facility fee, CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL 80% CBT 80% CBT No Benefit Subject to Medical Savings Account consumed meds and materials).

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 300 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 R2 014 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 R850 off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear Aquity Single Vision; Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R925.

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 R380 AND EITHER SPECTACLES - A frame benefit of R850 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 R925.

NETWORK CHOICE

MONTHLY CONTRIBUTION RATES
Network Choice
Monthly income based on Total Cost to Company of Principal MemberTotal Monthly Contribution
R0 - R22 410Principal
Adult
1st Child
(rest are free)
R2 070
R1 735
R   900
R22 411 - R30 040Principal
Adult
1st Child
(rest are free)
R2 465
R1 965
R1 110
R30 041 - R45 070Principal
Adult
Child
R2 945
R2 285
R1 470
R45 071+Principal
Adult
Child
R3 960
R3 195
R1 945

Monthly Contribution Rates

Alliance Plus
Monthly Risk Contribution
Adult     R7 825
Child     R4 232

Monthly MSA Contribution
Adult     R 625
Child     R 290

Total Monthly Contribution
Adult     R8 450
Child     R4 522




Alliance Network
Monthly Risk Contribution
Adult     R7 093
Child     R3 835

Monthly MSA Contribution
Adult     R 565
Child     R 260

Total Monthly Contribution
Adult     R7 658
Child     R4 095
Double Plus
Monthly Risk Contribution
Adult     R5 172
Child     R2 965

Monthly MSA Contribution
Adult     R 400
Child     R 260

Total Monthly Contribution
Adult     R5 572
Child     R3 225




Double Network
Monthly Risk Contribution
Adult     R4 710
Child     R2 691

Monthly MSA Contribution
Adult     R 370
Child     R 240

Total Monthly Contribution
Adult     R5 080
Child     R2 931
Vital Plus
Total monthly contribution for a monthly income ¹ of
R0 - R54 510

Adult       R2 955
Child       R1 515

Total monthly contribution for a monthly income ¹ of
R54 511 - R136 270

Adult       R3 350
Child       R1 710

Total monthly contribution for a monthly income ¹ of
R136 271+

Adult       R3 725
Child       R1 910



Vital Network
Total monthly contribution for a monthly income ¹ of
R0 - R54 510

Adult       R2 750
Child       R1 410

Total monthly contribution for a monthly income ¹ of
R54 511 - R136 270

Adult       R3 120
Child       R1 590

Total monthly contribution for a monthly income ¹ of
R136 271+

Adult       R3 470
Child       R1 775
Essential Plus
R0 - R136 270 ¹

Monthly Risk Contribution
Principal     R2 450
Adult           R1 935
Child           R1 140

Monthly MSA Contribution
Principal     R700
Adult           R560
Child           R330

Total Monthly Contribution
Principal     R3 150
Adult           R2 495
Child           R1 470

R136 271+ ¹

Monthly Risk Contribution
Principal     R2 950
Adult           R2 335
Child           R1 370

Monthly MSA Contribution
Principal     R700
Adult           R560
Child           R330

Total Monthly Contribution
Principal     R3 650
Adult           R2 895
Child           R1 700



Essential Network
R0 - R136 270 ¹

Monthly Risk Contribution
Principal     R2 210
Adult           R1 745
Child           R1 025

Monthly MSA Contribution
Principal     R630
Adult           R500
Child           R300

Total Monthly Contribution
Principal     R2 840
Adult           R2 245
Child           R1 325

R136 271+ ¹

Monthly Risk Contribution
Principal     R2 660
Adult           R2 110
Child           R1 235

Monthly MSA Contribution
Principal     R630
Adult           R500
Child           R300

Total Monthly Contribution
Principal     R3 290
Adult           R2 610
Child           R1 535
First Choice
Total monthly contribution for a monthly income ¹ of
R0 - R11 620

Adult       R1 455
Child       R885

Total monthly contribution for a monthly income ¹ of
R11 621 - R22 410

Adult       R2 310
Child       R1 370

Total monthly contribution for a monthly income ¹ of
R22 411 - R30 040

Adult       R3 470
Child       R2 020

Total monthly contribution for a monthly income ¹ of
R30 041 - R45 070

Adult       R4 360
Child       R2 870

Total monthly contribution for a monthly income ¹ of
R45 071+

Adult       R4 770
Child       R3 115
Network Choice
Total monthly contribution for a monthly income ¹ of
R0 - R22 410

Principal     R2 070
Adult           R1 735
1st Child     R900
(rest are free)

Total monthly contribution for a monthly income ¹ of
R22 411 - R30 040

Principal     R2 465
Adult           R1 965
1st Child     R1 110
(rest are free)

Total monthly contribution for a monthly income ¹ of
R30 041 - R45 070

Principal     R2 945
Adult           R2 285
Child           R1 470

Total monthly contribution for a monthly income ¹ of
R45 071+

Principal     R3 960
Adult           R3 195
Child           R1 945

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

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Chronic Disease List - PMB CDL Conditions - All Options

ConditionConsultationLevel of Consultation Cover
ADDISON’S DISEASEGeneral Practitioner (GP), Physician, Paediatrician100% COST
ASTHMA*GP, Physician, Pulmonologist, Paediatrician100% COST
BIPOLAR MOOD DISORDER*Psychiatrist, Clinical Psychologist, Social Worker100% COST
BRONCHIECTASIS*GP, Physician, Pulmonologist, Physiotherapist100% COST
CARDIAC FAILUREGP, Physician, Cardiologist100% COST
CARDIOMYOPATHYGP, Physician, Cardiologist100% COST
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)*GP, Physician, Pulmonologist, Physiotherapist100% COST
CHRONIC RENAL DISEASEGP, Physician100% COST
CORONARY ARTERY DISEASEGP, Physician, Cardiologist, Dietician100% COST
CROHN’S DISEASEGP, Gastroenterologist, Physician, General Surgeon100% COST
DIABETES INSIPIDUSGP, Physician, Paediatrician, Endocrinologist100% COST
DIABETES MELLITUS (TYPE 1 AND TYPE 2)*GP, Physician, Paediatrician, Ophthalmologist, Dietician, Podiatrist, Endocrinologist100% COST
DYSRHYTHMIAGP, Physician, Cardiologist, Paediatrician100% COST
EPILEPSYGP, Physician, Neurologist, Paediatrician100% COST
GLAUCOMAGP, Physician, Ophthalmologist100% COST
HAEMOPHILIA A & BGP, Physician, Paediatrician, Haematologist100% COST
HIV/AIDS**GP, Physician, Paediatrician100% COST
HYPERLIPIDAEMIA*GP, Physician, Cardiologist, Paediatrician, Dietician100% COST
HYPERTENSION*GP, Physician, Cardiologist, Dietician100% COST
HYPOTHYROIDISMGP, Physician, Paediatrician100% COST
MULTIPLE SCLEROSISGP, Physician, Neurologist, Ophthalmologist, Urologist, Occupational Therapist, Physiotherapist100% COST
PARKINSON’S DISEASEGP, Physician, Neurologist100% COST
Rheumatoid ArthritisGP, Physician, Rheumatologist, Paediatrician100% COST
SCHIZOPHRENIA*Psychiatrist, Clinical Psychologist, Social Worker100% COST
SYSTEMIC LUPUS ERYTHEMATOSISGP, Physician, Dermatologist, Paediatrician100% COST
ULCERATIVE COLITISGastroenterologist, GP, Physician100% 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

ConditionConsultationsLevel of Consultation Cover
ADHD (Alliance Plus & Alliance Network only)Paediatrician, Neurologist, Psychiatrist100% CBT
ALLERGIC RHINITISGP, Ear Nose and Throat Specialist (ENT), Paediatrician100% CBT
ALZHEIMER’S DISEASENeurologist, Psychiatrist100% CBT
ANKYLOSING SPONDYLITISPhysician, Rheumatologist100% CBT
BENIGN PROSTATIC HYPERTROPHYUrologist100% CBT
CHRONIC GRANULOMATOUS DISEASEPhysician100% CBT
COAGULATION DISORDERSCardiologist, Physician, Clinical Haemotologist100% CBT
CONGENITAL HEART MALFORMATIONSPhysician, Cardiologist, Paediatrician100% CBT
CYSTIC FIBROSISPhysician, Physiotherapist, Pulmonologist, Paediatrician, GP100% CBT
DEEP VEIN THROMBOSISPhysician100% CBT
DEPRESSION (includes First Choice, Network Choice, Essential Plus and Essential Network)GP, Psychiatrist, Clinical Psychologist, Social Worker100% CBT
ECZEMADermatologist, GP100% CBT
ENDOMETRIOSISGynaecologist100% CBT
GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)GP, Gastroenterologist, Physician, Paediatrician100% CBT
GAUCHERS DISEASEPhysician, Paediatrician100% CBT
GOUT PROPHYLAXISGP100% CBT
HORMONE REPLACEMENTGP100% CBT
HYPERPARATHYROIDISMPhysician100% CBT
HYPERTHYROIDISMGP, Paediatrician100% CBT
MENIERE’S DISEASEGP, Ear Nose and Throat Specialist (ENT)100% CBT
MIGRAINE PROPHYLAXISGP, Neurologist100% CBT
MUSCULAR DYSTROPHYNeurologist, Physician, Paediatrician100% CBT
MYASTHENIA GRAVISPhysician100% CBT
NARCOLEPSYNeurologist100% CBT
ORGAN TRANSPLANTAppropriate multi disciplinary team100% CBT
OSTEOARTHRITISPhysician, Rheumatologist, GP100% CBT
OSTEOPOROSISPhysician, Gynaecologist, GP100% CBT
PERVASIVE DEVELOPMENTAL DISORDER (PDD) (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY)GP, Pediatrician, Neurologist, Psychiatrist100% CBT
PLEGIA; HEMI, PARA & QUADPhysician, Orthopaedic Surgeon, Physiotherapist, Urologist, Neurologist, Occupational Therapist, Paediatrician, Speech Therapist, GP100% CBT
POLYCYSTIC OVARIAN SYNDROMEGynaecologist100% CBT
PSORIASISDermatologist100% CBT
RESTRICTIVE LUNG DISEASEPulmonologist, Physician100% CBT
TRANSIENT ISCHAEMIC ATTACK / STROKEPhysician, Neurologist100% CBT
TUBERCULOSISGP100% CBT
VALVULAR HEART DISEASEPhysician, Cardiologist, Paediatrician100% CBT

ICD10 Codes 2024

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

CAMAF Benefit Option 2024 - Pdf Download

Glossary

ADULTRefers to the member and dependants who are 22 or older at any time in the year of cover.
CBTCAMAF 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.
CDLChronic Disease List - the list of PMB’s includes 27 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/ FORMULARYCondition 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.
CHILDRefers to a dependant who is younger than an adult, as defined above.
DISPENSING FEESFee negotiated by the Scheme with Network pharmacies and added to SEP.
DSPThe 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.
DTPThe 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 CODEStands 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.
INCOMETotal cost to company prior to deductions.
MEDICAL EMERGENCYA sudden and, at the time, unexpected onset of a health condition or injury that needs immediate attention, where failure to provide such attention could result in the risk of loss of life or permanent damage to a bodily function or body part.
MEDICAL SAVINGS ACCOUNT (MSA)A savings account that accrues monthly but the annualised amount of savings is available immediately and can be used for:
• top up on cost of service charged by a doctor
• extension when an overall benefit has been exceeded
• exclusion from benefits
• payment of day to day claims on Essential Plus and Essential Network options
METABOLIC SCREENINGNewborn screening whereby rare disorders are detected by a blood test done 48 - 72 hours after birth.
MMAPMaximum 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 RATEThis 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.
PMBPrescribed 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)
• 27 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-AUTHORISATIONA 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.
PROTOCOLMeans 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 CONTRIBUTIONSThose funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account.
RPReference 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.
SEPSingle 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

CAMAF BENEFIT OPTION 2024 – PDF DOWNLOAD