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.
This brochure is for summary purposes only and does not supersede the rules of the Scheme in any way.
Please note that all 2025 Benefit Option information, benefits and limits are subject to Council for Medical Schemes (CMS) approval.
CAMAF BENEFIT OPTION 2025 – PDF DOWNLOAD
  |   |   |   |  |  |
|
|---|---|---|---|---|---|---|
| Hospital Facility | Alliance 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 hospital | Netcare hospitals only |
| Cover For Attending Doctors and Specialists In Hospital | 300% CBT | 300% CBT | 300% CBT | 200% CBT | 100% CBT | 100% CBT |
| Chronic Condition Cover: Medicines and Consults | 65 Conditions List of conditions Additional conditions | 64 Conditions List of conditions Additional conditions | 60 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 Hospital, Limits apply to Out of Hospital | Unlimited In Hospital, Out of Hospital from MSA | Limits apply In and Out of Hospital | Limits apply In and Out of Hospital |
| Preventive Wellness Benefits | 14 extra benefits | 14 extra benefits | 14 extra benefits | 14 extra benefits | 11 extra benefits | 11 extra benefits |
| Day To Day Overall Limit | R43 964 | R17 129 | - | Limited to funds available in the beneficiary’s Medical Savings Account | R4 118 for medicines. R8 630 for advanced dentistry R4 118 for other. R12 670 for specialists. Paid at 80% | R4 118 for medicines. R8 630 for advanced dentistry R4 118 for other. R12 670 for specialists. From DSP only |
| Annual Overall limit for out of hospital benefits other than day to day benefits | Unlimited, limits and sub-limits per benefit category applies where applicable | Unlimited, limits and sub-limits per benefit category applies where applicable | R20,000 | Subject to Medical Savings Account | Unlimited, limits and sub-limits per benefit category applies where applicable | Unlimited, limits and sub-limits per benefit category applies where applicable |
| 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 | - | - |
 |
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 medication for CDL chronic conditions, limited benefits for additional chronic conditions 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, Insulin pump, 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 R112 152 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 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 | 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 100% DSP Tariff for Alliance Network |
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 R112 152 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 (For Alliance Network - on referral from a nominated network GP) |
PMB DTP TREATMENT | 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 | 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.
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 | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy and free Online Wellness Club. |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary. (Nominated Network GP for Alliance Network) |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R17 088 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) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates (PPN is the DSP for Alliance Network) |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, limited to R6 907 per beneficiary |
HUMAN PAPILLOMA VIRUS (HPV) VACCINE | 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.
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 LIMIT | Baby Apnoea Monitors: R3 541 Breast pumps: R5 793 |
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 388 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.
| OUT OF HOSPITAL BENEFITS OTHER THAN DAY-TO-DAY BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
OVERALL ANNUAL LIMIT | Unlimited, limits and sub-limits per benefit category applies where applicable |
BASIC AND ADVANCED RADIOLOGY | 100% CBT (on referral from a nominated network GP or a specialist for Alliance Network) |
PATHOLOGY | 100% Negotiated Rate or CBT (on referral from a nominated network GP or a specialist for Alliance Network) |
POST-HOSPITALISATION | 300% CBT for attending practitioners 100% CBT for supplementary services |
MEDICATION AND TREATMENT FOR ADDITIONAL CHRONIC CONDITIONS | 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) | 100% NAPPI price or 100% of cost, subject to the overall external appliance limit of R113 220 per beneficiary and subject to the following sub-limits: Hearing Aids: R113 220 Wheelchairs for Quadriplegics: R113 220 Standard Wheelchairs: R67 554 Insulin Pumps: R67 554 Other external appliances: R22 415 (on referral from a nominated network GP or a specialist for Alliance Network) |
INTERNATIONAL TRAVEL COVER | 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 | 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.
| DAY-TO-DAY BENEFITS (per Beneficiary) SUBJECT TO THE DAY-TO-DAY ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
DAY-TO-DAY BENEFITS | Annual Overall Limits Adult R43 964 Child R27 380 |
GPs AND DENTISTS | 80% CBT Nominated Network GP for Alliance Network |
SPECIALISTS | 80% CBT (on referral from a nominated network GP for Alliance Network) |
ACUTE MEDICATION | 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 | 80% CBT (on referral from a nominated network GP or from a specialist for Alliance Network) |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | 80% CBT limited to: M0 R22 415 M1 R33 501 M2+ R40 402 |
OVER THE COUNTER MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R5 532 per beneficiary |
LASER K/EXCIMER LASER | 80% CBT limited to R16 974 per beneficiary per eye |
SPECTACLES AND LENSES | PPN is the DSP for Alliance Network Consultation: See Preventive Wellness Benefit Add-ons R2 199 Single vision R2 199 OR Bifocal R4 408 OR Varifocal R6 634 AND Frames R9 894 OR Contact lenses R9 616 Lenses, frames etc 80% Optical Assistant Rates |
| MONTHLY CONTRIBUTION RATES | |||
|---|---|---|---|
| |
||
| Monthly Risk Contribution | Adult Child | R8 905 R4 690 | R7 995 R4 225 |
| Monthly MSA Contribution | Adult Child | R 625 R 290 | R 565 R 260 |
| Total Monthly Contribution | Adult Child | R9 530 R4 980 | R8 560 R4 485 |
 |
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 medication for CDL chronic conditions, limited benefits for additional chronic conditions 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, Insulin pump, 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 R79 095 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 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 | 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 100% DSP Tariff for Double Network |
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 R79 095 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 (For Double Network - on referral from a nominated network GP) |
PMB DTP TREATMENT | 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 | 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.
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 | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy and free Online Wellness Club |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary (nominated Network GP for Double Network) |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R17 088 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) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates (PPN optometrist for Double Network) |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, limited to: Adults R3 468 Child R5 737 |
HUMAN PAPILLOMA VIRUS (HPV) VACCINE | 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.
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 LIMIT | Baby Apnoea Monitors: R3 472 Breast pumps: R5 793 |
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 484 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.
| OUT OF HOSPITAL BENEFITS OTHER THAN DAY-TO-DAY BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
OVERALL ANNUAL LIMIT | Unlimited, limits and sub-limits per benefit category applies where applicable |
BASIC AND ADVANCED RADIOLOGY | 100% CBT (on referral from a nominated network GP or a specialist for Double Network) |
PATHOLOGY | 100% Negotiated Rate or CBT (on referral from a nominated network GP or a specialist for Double Network) |
POST-HOSPITALISATION | 300% CBT for attending practitioners 100% CBT for supplementary services |
MEDICATION AND TREATMENT FOR ADDITIONAL | 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) | 100% NAPPI price or 100% of cost, subject to the overall external appliance limit of R90 513 per beneficiary and subject to the following sub-limits: Hearing Aids: R90 513 Wheelchairs for Quadriplegics: R90 513 Standard Wheelchairs: R57 733 Insulin Pumps: R59 112 Other external appliances: R19 410 (on referral from a nominated network GP or a specialist for Double Network) |
INTERNATIONAL TRAVEL COVER | 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 | 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.
| DAY-TO-DAY BENEFITS (per Beneficiary) SUBJECT TO THE DAY-TO-DAY ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
DAY-TO-DAY BENEFITS | Annual Overall Limits Adult R17 129 Child R11 887 |
GPs AND DENTISTS | 80% CBT Nominated Network GP for Double Network |
SPECIALISTS | 80% CBT (on referral from a nominated network GP for Double Network) |
ACUTE MEDICATION | 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 | 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 | 80% CBT (on referral from a nominated network GP or a specialist for Double Network) |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | 80% CBT limited to: M0 R16 695 M1 R24 041 M2+ R32 377 |
OVER THE COUNTER MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R2 454 per beneficiary |
LASER K/EXCIMER LASER | 80% CBT limited to R6 267 per beneficiary per eye |
SPECTACLES AND LENSES | PPN is the DSP for Double Network Consultation: See Preventive Wellness Benefit Add ons R1 447 Single vision R1 447 OR Bifocal R3 862 OR Varifocal R5 921 AND Frames R5 320 OR Contact lenses R5 164 Lenses, frames etc 80% Optical Assistant Rates |
| MONTHLY CONTRIBUTION RATES | |||
|---|---|---|---|
| |
||
| Monthly Risk Contribution | Adult Child | R5 875 R3 370 | R5 315 R3 035 |
| Monthly MSA Contribution | Adult Child | R 400 R 260 | R 370 R 240 |
| Total Monthly Contribution | Adult Child | R6 275 R3 630 | R5 685 R3 275 |
 |
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 |
 |
60 Chronic Conditions: Medication and consultations. Covers the medication and necessary consultations and procedures. Includes appropriate biological medication for CDL chronic conditions and specialised technology |
 |
Unlimited X-Rays and Blood Tests IN hospital, limits apply to advanced scans |
 |
Screening Benefits: Melanoma, PSA, Pap Smear, Mammogram |
 |
3 Months post-hospitalisation benefit |
 |
External Appliances: Wheelchair, hearing aid, breast pump, baby sleep monitor, Insulin pump |
 |
Checkups 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 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 | 100% CBT |
BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
RADIOLOGY IN HOSPITAL | 100% CBT 100% CBT limited to 2 scans in and out of hospital combined |
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 100% DSP Tariff for Vital Network |
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 | 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 DSP is the ICON network. The ICON Core protocols 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.
| PREVENTIVE WELLNESS COVER | |
|---|---|
CAMAF PREVENTIVE WELLNESS PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy and free Online Wellness Club |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R17 088 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) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, limited to R2 298 per beneficiary |
HUMAN PAPILLOMA VIRUS (HPV) VACCINE | 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.
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 LIMIT | Baby Apnoea Monitors: R3 472 (subject to overall annual limit) Breast pumps: R5 793 (subject to overall annual limit) |
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.
| OUT OF HOSPITAL BENEFITS OTHER THAN DAY-TO-DAY BENEFITS (per Beneficiary) SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT OF R20 000 |
|
|---|---|
OVERALL ANNUAL LIMIT | R20 000 Overall Limit per Beneficiary |
BASIC AND ADVANCED RADIOLOGY | 100% CBT limited to R10 000 (subject to overall annual limit) 2 Advanced scans (In & out of hospital) |
PATHOLOGY | 100% negotiated Rate or CBT limited to R5 000 (subject to overall annual limit) |
POST-HOSPITALISATION | 300% CBT for attending practitioners 100% CBT for supplementary services Subject to overall annual limit |
MEDICATION AND TREATMENT FOR ADDITIONAL | 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT. Limited to R13 000 per beneficiary. |
EXTERNAL APPLIANCES (subject to referral) | 100% NAPPI price or 100% of cost, subject to the overall external appliance annual limit of R20 000 per beneficiary and subject to the following sub-limits: Hearing Aids: R20 000 Other external appliances: R11 347 NOT SUBJECT TO THE OVERALL ANNUAL LIMIT: Wheelchairs for Quadriplegics: R45 272 Standard Wheelchairs: R31 793 Insulin Pumps: R52 094 |
INTERNATIONAL TRAVEL COVER | 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 | 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.
| DAY-TO-DAY BENEFITS (per Beneficiary) SUBJECT TO THE DAY-TO-DAY ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
DAY-TO-DAY BENEFITS | No Benefit |
GP's AND DENTISTS | No Benefit |
SPECIALISTS | No Benefit |
ACUTE MEDICATION | No Benefit |
NON-DSP VISITS | Not applicable |
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL | No Benefit |
NURSE VISITS | No Benefit |
SUPPLEMENTARY HEALTH | No Benefit |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | No Benefit |
OVER THE COUNTER MEDICATION | No Benefit |
LASER K/EXCIMER LASER | No Benefit |
SPECTACLES AND LENSES | Consultation: Part of Preventive Wellness |
| MONTHLY CONTRIBUTION RATES | |||
|---|---|---|---|
| |
||
| Monthly income as defined in the Scheme Rules | Total Monthly Contribution | ||
| R0 - R57 240 | Adult Child | R3 435 R1 760 | R3 165 R1 625 |
| R57 241 – R143 080 | Adult Child | R3 895 R1 985 | R3 600 R1 840 |
| R143 081+ | Adult Child | R4 350 R2 225 | R4 000 R2 050 |
 |
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 |
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 | 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 100% DSP Tariff for Essential Network |
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 | 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 protocols 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.
| PREVENTIVE WELLNESS COVER | |
|---|---|
CAMAF PREVENTIVE WELLNESS PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy and free Online Wellness Club |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R17 088 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) | 100% CBT per adult beneficiary |
ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, limited to R2 435 per beneficiary |
HUMAN PAPILLOMA VIRUS (HPV) VACCINE | 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.
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 LIMIT | 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.
| OUT OF HOSPITAL BENEFITS OTHER THAN DAY-TO-DAY BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
OVERALL ANNUAL LIMIT | Subject to Medical Savings Account |
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 | 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 | 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.
| DAY-TO-DAY BENEFITS (per Beneficiary) SUBJECT TO THE DAY-TO-DAY 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 CONTRIBUTION RATES | |||
|---|---|---|---|
| |
||
| Monthly income as defined in the Scheme Rules | Total Monthly Contribution | ||
| R0 - R143 080 | |||
| Monthly Risk Contribution | Principal Adult Child | R2 785 R2 200 R1 300 | R2 490 R1 970 R1 155 |
| Monthly MSA Contribution | Principal Adult Child | R 700 R 560 R 330 | R 630 R 500 R 300 |
| Total Monthly Contribution | Principal Adult Child | R3 485 R2 760 R1 630 | R3 120 R2 470 R1 455 |
| R143 081+ | |||
| Monthly Risk Contribution | Principal Adult Child | R3 415 R2 700 R1 590 | R3 025 R2 395 R1 405 |
| Monthly MSA Contribution | Principal Adult Child | R 700 R 560 R 330 | R 630 R 500 R 300 |
| Total Monthly Contribution | Principal Adult Child | R4 115 R3 260 R1 920 | R3 655 R2 895 R1 705 |
 |
Any Private Hospital – No limits |
 |
Attending Doctors and Specialists: 100% CBT |
 |
27 Chronic Conditions: medication and consultations. |
 |
Radiology Advanced scans limited to R47 586 per family and R5 565 per beneficiary for basic radiology |
 |
Screening Benefits: PSA, Pap Smear, Mammogram |
 |
80% of GP, Specialists, Dental, Optometry, Checkups, 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 CHILDBIRTH CONFINEMENTS, | 100% of Negotiated Rate in general ward and specialised units |
ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS | 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 R47 586 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 R47 586 per family Exclusions: cochlear implants |
HOME NURSING | 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 | 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 protocols 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.
| PREVENTIVE WELLNESS COVER | |
|---|---|
CAMAF PREVENTIVE WELLNESS PROGRAMME | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy and free Online Wellness Club. |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R17 088 per beneficiary |
ONE DENTISTRY CONSULTATION GENERAL CHECKUP 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 R2 335 per beneficiary |
HUMAN PAPILLOMA VIRUS (HPV) VACCINE | 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.
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 LIMIT | Baby Apnoea Monitors: R2 838 Breast pumps: R4 880 |
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 subject to sub-limit R1 308 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.
| OUT OF HOSPITAL BENEFITS OTHER THAN DAY-TO-DAY BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
OVERALL ANNUAL LIMIT | Unlimited, limits and sub-limits per benefit category applies where applicable |
BASIC AND ADVANCED RADIOLOGY | Basic Radiology: 100% CBT limited to R5 565 per beneficiary Advanced scans: 100% CBT limited to R47 586 per family for in and out of hospital |
PATHOLOGY | 100% negotiated rate or CBT limited to R8 880 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 external appliance limit of R8 498 per beneficiary |
INTERNATIONAL TRAVEL COVER | 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 | 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.
| DAY-TO-DAY BENEFITS (per Beneficiary) SUBJECT TO THE DAY-TO-DAY ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
DAY-TO-DAY BENEFITS | Annual overall limit: Beneficiary specific limits: (a) Medicines R4 118 (b) Advanced Dentistry R8 630 (c) Other R4 118 (d) Specialists R12 670 |
GPs 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 R3 465 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 R2 115 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 R935 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 R970. 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 R935 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 R970. |
| MONTHLY CONTRIBUTION RATES | ||
|---|---|---|
 |
||
| Monthly income as defined in the Scheme Rules | Total Monthly Contribution | |
| R0 - R12 200 | Adult Child | R1 600 R 965 |
| R12 201 – R23 530 | Adult Child | R2 580 R1 515 |
| R23 531 – R31 540 | Adult Child | R3 860 R2 235 |
| R31 541 – R47 320 | Adult Child | R4 855 R3 205 |
| R47 321+ | Adult Child | R5 365 R3 500 |
 |
Network Hospital: No limits (DSP hospital group is Netcare) (20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies) |
 |
Attending Doctors: 100% CBT only at DSP |
 |
27 Chronic Conditions: medication and consultations. |
 |
Radiology Advanced scans limited to R47 586 per family and R5 565 per beneficiary for basic radiology (on referral by nominated GP or specialist for out of hospital) |
 |
Screening Benefits: PSA, Pap Smear, Mammogram |
 |
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 CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | 100% DSP tariff as per protocols. The DSP hospital group is 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 | 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 R47 586 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 R47 586 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 - 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 (on referral from a nominated network GP) |
PMB DTP TREATMENT | 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 | 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
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 | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy and free Online Wellness Club. |
ONE GP CONSULTATION ONLY | 100% CBT per beneficiary (Nominated Network GP only) |
ONE SPECIALIST CONSULTATION | 100% CBT per beneficiary |
PSYCHOTHERAPY | 100% CBT limited to R17 088 per beneficiary |
ONE DENTISTRY CONSULTATION GENERAL CHECKUP 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 R2 335 per beneficiary |
HUMAN PAPILLOMA VIRUS (HPV) VACCINE | 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.
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 LIMIT | Baby Apnoea Monitors: R2 838 Breast pumps: R4 880 |
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 subject to sub-limit R1 308 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.
| OUT OF HOSPITAL BENEFITS OTHER THAN DAY-TO-DAY BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
OVERALL ANNUAL LIMIT | Unlimited, limits and sub-limits per benefit category applies where applicable |
BASIC AND ADVANCED RADIOLOGY | Basic Radiology: Referrals by nominated network GP or specialist, 100% CBT limited to R5 565 per beneficiary Advanced scans: 100% CBT limited to R47 586 per family for in and out of hospital (on referral by a nominated network GP or specialist) |
PATHOLOGY | Referred by nominated network GP or specialist, 100% negotiated rate or CBT, limited to R8 880 per beneficiary |
MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS | Depression only. 100% SEP plus a dispensing fee subject to RP and DSP Consultations 100% CBT (on referral from a nominated network GP; medication claims will not be paid if non-nominated network GP is used) |
EXTERNAL APPLIANCES (subject to referral) | 100% NAPPI price or 100% of cost, limited to R8 498 per beneficiary and subject to a nominated network GP or Specialist referral |
INTERNATIONAL TRAVEL COVER | 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 | 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.
| DAY-TO-DAY BENEFITS (per Beneficiary) SUBJECT TO THE DAY-TO-DAY ANNUAL OVERALL BENEFIT LIMIT |
|
|---|---|
DAY-TO-DAY BENEFITS | Annual overall limit: Beneficiary specific limits: (a) Medicines R4 118 (b) Advanced Dentistry R8 630 (c) Other R4 118 (d) Specialists R12 670 |
GPs AND DENTISTS | 100% negotiated rate subject to sublimit (c) - Nominated Network GP only |
SPECIALISTS | 100% CBT Subject to limit (d) (on referral from a nominated network GP only) |
ACUTE MEDICATION | 100% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a) (on referral from a nominated network GP only) |
NON-DSP VISITS | Both the non-nominated GP visit and casualty treatment is limit to R1 759 per family One non-network or non-nominated GP visit per beneficiary (including casualty and GP). 20% co-payment AND Casualty visits (facility fee, consumed meds and materials only |
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL |
|
NURSE VISITS | 100% CBT subject to limit (c) |
SUPPLEMENTARY HEALTH | 100% CBT limited to R3 465 per beneficiary on referral from a nominated network GP 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 R2 115 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 R935 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 R970. 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 R935 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 R970. |
| MONTHLY CONTRIBUTION RATES | ||
|---|---|---|
 |
||
| Monthly income as defined in the Scheme Rules | Total Monthly Contribution | |
| R0 - R23 530 | Principal Adult 1st Child (rest are free) | R2 275 R1 907 R1 005 |
| R23 531 – R31 540 | Principal Adult 1st Child (rest are free) | R2 710 R2 160 R1 238 |
| R31 541 – R47 320 | Principal Adult Child | R3 290 R2 555 R1 640 |
| R47 321+ | Principal Adult Child | R4 435 R3 585 R2 185 |
Monthly Risk Contribution Adult R8 905 Child R4 690 Monthly MSA Contribution Adult R 625 Child R 290 Total Monthly Contribution Adult R9 530 Child R4 980 Monthly Risk Contribution Adult R7 995 Child R4 225 Monthly MSA Contribution Adult R 565 Child R 260 Total Monthly Contribution Adult R8 560 Child R4 485 | Monthly Risk Contribution Adult R5 875 Child R3 370 Monthly MSA Contribution Adult R 400 Child R 260 Total Monthly Contribution Adult R6 275 Child R3 630 Monthly Risk Contribution Adult R5 315 Child R3 035 Monthly MSA Contribution Adult R 370 Child R 240 Total Monthly Contribution Adult R5 685 Child R3 275 | Total monthly contribution for a monthly income ¹ of R0 - R57 240 Adult R3 435 Child R1 760 Total monthly contribution for a monthly income ¹ of R57 241 – R143 080 Adult R3 895 Child R1 985 Total monthly contribution for a monthly income ¹ of R143 081+ Adult R4 350 Child R2 225 Total monthly contribution for a monthly income ¹ of R0 - R57 240 Adult R3 165 Child R1 625 Total monthly contribution for a monthly income ¹ of R57 241 – R143 080 Adult R3 600 Child R1 840 Total monthly contribution for a monthly income ¹ of R143 081+ Adult R4 000 Child R2 050 | R0 - R143 080 ¹ Monthly Risk Contribution Principal R2 785 Adult R2 200 Child R1 300 Monthly MSA Contribution Principal R700 Adult R560 Child R330 Total Monthly Contribution Principal R3 485 Adult R2 760 Child R1 630 R143 081+ ¹ Monthly Risk Contribution Principal R3 415 Adult R2 700 Child R1 590 Monthly MSA Contribution Principal R700 Adult R560 Child R330 Total Monthly Contribution Principal R4 115 Adult R3 260 Child R1 920 R0 - R143 080 ¹ Monthly Risk Contribution Principal R2 490 Adult R1 970 Child R1 155 Monthly MSA Contribution Principal R630 Adult R500 Child R300 Total Monthly Contribution Principal R3 120 Adult R2 470 Child R1 455 R143 081+ ¹ Monthly Risk Contribution Principal R3 025 Adult R2 395 Child R1 405 Monthly MSA Contribution Principal R630 Adult R500 Child R300 Total Monthly Contribution Principal R3 655 Adult R2 895 Child R1 705 | Total monthly contribution for a monthly income ¹ of R0 - R12 200 Adult R1 600 Child R965 Total monthly contribution for a monthly income ¹ of R12 201 – R23 530 Adult R2 580 Child R1 515 Total monthly contribution for a monthly income ¹ of R23 531 – R31 540 Adult R3 860 Child R2 235 Total monthly contribution for a monthly income ¹ of R31 541 – R47 320 Adult R4 855 Child R3 205 Total monthly contribution for a monthly income ¹ of R47 321+ Adult R5 365 Child R3 500 | Total monthly contribution for a monthly income ¹ of R0 - R23 530 Principal R2 275 Adult R1 907 1st Child R1 005 (rest are free) Total monthly contribution for a monthly income ¹ of R23 531 – R31 540 Principal R2 710 Adult R2 160 1st Child R1 238 (rest are free) Total monthly contribution for a monthly income ¹ of R31 541 – R47 320 Principal R3 290 Adult R2 555 Child R1 640 Total monthly contribution for a monthly income ¹ of R47 321+ Principal R4 435 Adult R3 585 Child R2 185 |
¹ Monthly income as defined in the Scheme Rules
| 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.
| Condition | Consultations | Level of Consultation Cover |
|---|---|---|
| ADHD (Alliance Plus & Alliance Network ONLY) | Paediatrician, Neurologist, Psychiatrist | 100% CBT |
| ALLERGIC RHINITIS | GP, Ear Nose and Throat Specialist (ENT), Paediatrician | 100% CBT |
| ALZHEIMER’S DISEASE | Neurologist, Psychiatrist | 100% CBT |
| ANKYLOSING SPONDYLITIS | Physician, Rheumatologist | 100% CBT |
| BENIGN PROSTATIC HYPERTROPHY | Urologist | 100% CBT |
| CHRONIC GRANULOMATOUS DISEASE (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY) | Physician | 100% CBT |
| COAGULATION DISORDERS | Cardiologist, Physician, Clinical Haemotologist | 100% CBT |
| CONGENITAL HEART MALFORMATIONS | Physician, Cardiologist, Paediatrician | 100% CBT |
| CYSTIC FIBROSIS | Physician, Physiotherapist, Pulmonologist, Paediatrician, GP | 100% CBT |
| DEEP VEIN THROMBOSIS | Physician | 100% CBT |
| DEPRESSION (includes First Choice, Network Choice, Essential Plus and Essential Network) | GP, Psychiatrist, Clinical Psychologist, Social Worker | 100% CBT |
| ECZEMA | Dermatologist, GP | 100% CBT |
| ENDOMETRIOSIS | Gynaecologist | 100% CBT |
| GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD) | GP, Gastroenterologist, Physician, Paediatrician | 100% CBT |
| GAUCHERS DISEASE | Physician, Paediatrician | 100% CBT |
| GOUT PROPHYLAXIS | GP | 100% CBT |
| HORMONE REPLACEMENT | GP | 100% CBT |
| HYPERPARATHYROIDISM | Physician | 100% CBT |
| HYPERTHYROIDISM | GP, Paediatrician | 100% CBT |
| MENIERE’S DISEASE | GP, Ear Nose and Throat Specialist (ENT) | 100% CBT |
| MIGRAINE PROPHYLAXIS | GP, Neurologist | 100% CBT |
| MUSCULAR DYSTROPHY | Neurologist, Physician, Paediatrician | 100% CBT |
| MYASTHENIA GRAVIS | Physician | 100% CBT |
| NARCOLEPSY (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY) | Neurologist | 100% CBT |
| ORGAN TRANSPLANT | Appropriate multi disciplinary team | 100% CBT |
| OSTEOARTHRITIS | Physician, Rheumatologist, GP | 100% CBT |
| OSTEOPOROSIS | Physician, Gynaecologist, GP | 100% CBT |
| PERVASIVE DEVELOPMENTAL DISORDER (PDD) (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY) | GP, Pediatrician, Neurologist, Psychiatrist | 100% CBT |
| PLEGIA; HEMI, PARA & QUAD | Physician, Orthopaedic Surgeon, Physiotherapist, Urologist, Neurologist, Occupational Therapist, Paediatrician, Speech Therapist, GP | 100% CBT |
| POLYCYSTIC OVARIAN SYNDROME | Gynaecologist | 100% CBT |
| PSORIASIS | Dermatologist | 100% CBT |
| RESTRICTIVE LUNG DISEASE (Alliance Plus, Alliance Network, Double Plus and Double Network ONLY) | Pulmonologist, Physician | 100% CBT |
| TRANSIENT ISCHAEMIC ATTACK / STROKE | Physician, Neurologist | 100% CBT |
| TUBERCULOSIS | GP | 100% CBT |
| VALVULAR HEART DISEASE | Physician, Cardiologist, Paediatrician | 100% CBT |
| 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 |
| 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 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/ 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), hearConnect for audiology benefits, PPN for optical benefits, , Pharmacy networks for all chronic medications, Netcare 911 for emergency transport, Netcare hospital group for Network Choice hospital admissions and Life Healthcare and Netcare hospital groups for Alliance Network, Double Network, Vital Network and Essential Network for hospital admissions. |
| DTP | The Regulations to the Medical Schemes Act in Annexure A provide a list of conditions identified as Prescribed Minimum Benefits. The List is in the form of Diagnosis Treatment Pairs (DTP’s). A DTP links a specific diagnosis to a treatment/procedure and therefore broadly indicates how each of the 271 PMB conditions should be treated. These treatment pairs cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s). |
| ICD 10 CODE | 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 EMERGENCY | A sudden and, at the time, unexpected onset of a health condition or injury that needs immediate attention, where failure to provide such attention could result in the risk of loss of life or permanent damage to a bodily function or body part. |
| 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 • payment of day to day claims on Essential Plus and Essential Network options • positive MSA may be used to fund exclusions from benefits |
| 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. |
| NOMINATED GP | Each beneficiary on Alliance Network, Double Network and Network Choice options needs to nominate a Network GP each year and use that GP only. An alternative nominated GP will be allowed should the primary nominated GP not be available. This is to improve care co-ordination. |
| PMB | Prescribed Minimum Benefits - as set out in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the diagnosis, treatment and care of: • Any emergency medical condition • A limited set of 271 medical conditions (Defined in DTP’s) • 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-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 20 000. 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. |
*More details available on the website www.camaf.co.za
– for full explanations, consult the Registered Rules
