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.
CAMAF BENEFIT OPTION 2026 – PDF DOWNLOAD
  |   |   |   |  |  |
|
|---|---|---|---|---|---|---|
| Hospital Facility | Alliance Plus Any private hospital. Private wards for childbirth confinements (subject to availability and pre-authorisation). Alliance Network * Life Healthcare, Netcare. Private wards for childbirth confinements (subject to availability and pre-authorisation). | 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 | 13 extra benefits | 13 extra benefits |
| Day To Day Overall Limit | Adult R46 160 Child R28 750 | Adult R17 985 Child R12 480 | - | Limited to funds available in the beneficiary’s Medical Savings Account | R4 325 for medicines. R9 060 for advanced dentistry R4 325 for other. R13 300 for specialists. Paid at 80% CBT | R4 325 for medicines. R9 060 for advanced dentistry R4 325 for other. R13 300 for specialists. DSPs apply |
| 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 | R21 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 800 Alliance Network: R7 080 | Double Plus: R4 980 Double Network: R4 620 | - | Essential Plus: R8 760 Essential Network: R7 860 | - | - |
* 20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies.
View Alliance Plus & Alliance Network benefit option summary
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 R117 760 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.
| CAMAF PREVENTIVE WELLNESS PROGRAMME (per Adult Beneficiary) | |
|---|---|
CAMAF PREVENTIVE WELLNESS PROGRAMME | INCLUDES: 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 945 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 R7 220 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) |
ONE HEALTH RISK ASSESSMENT (HRA) | Limited to lower of 100% Negotiated rate or cost per beneficiary |
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 720 Breast pumps: R6 085 |
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 560 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 R118 880 per beneficiary and subject to the following sub-limits: Hearing Aids (reimbursed at DSP rates): R118 880 Wheelchairs for Quadriplegics: R118 880 Standard Wheelchairs: R70 930 Insulin Pumps: R70 930 Other external appliances: R23 535 (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. Prior to departure from South Africa, members are required to declare their upcoming journey to activate this coverage. 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 R46 160 Child R28 750 |
GPs AND DENTISTS | 80% CBT Nominated Network GP for Alliance Network |
SPECIALISTS - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 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 - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 80% CBT (on referral from a nominated network GP or from a specialist for Alliance Network) |
SPECTACLES AND LENSES | PPN is the DSP for Alliance Network Consultation: See Preventive Wellness Benefit Add-ons R2 310 Single vision R2 310 OR Bifocal R4 630 OR Varifocal R6 965 AND Frames R10 390 OR Contact lenses R10 100 Lenses, frames etc 80% Optical Assistant Rates SUBJECT TO THE OVERALL DAY-TO-DAY BENEFIT LIMITS |
OVER THE COUNTER MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R5 810 per beneficiary |
HEALTH CHECK BOOST | R500 per beneficiary Not available for pharmacy benefits. |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | 80% CBT limited to: M0 R23 535 M1 R35 175 M2+ R42 420 |
DENTAL IMPLANTS | R68 250 per beneficiary for the case as a whole (facility fee, tooth implant and provider accounts) |
LASER K/EXCIMER LASER | 80% CBT limited to R17 825 per beneficiary per eye |
| MONTHLY CONTRIBUTION RATES | |||
|---|---|---|---|
| |
||
| Monthly Risk Contribution | Adult Child | R9 885 | R8 875 |
| Monthly MSA Contribution | Adult Child | R650 | R590 |
| Total Monthly Contribution | Adult Child | R10 535 | R9 465 |
View Double Plus & Double Network benefit option summary
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 R83 050 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.
| CAMAF PREVENTIVE WELLNESS PROGRAMME (per Adult Beneficiary) | |
|---|---|
CAMAF PREVENTIVE PROGRAMME | INCLUDES: 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 945 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 625 Child R5 995 |
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) |
ONE HEALTH RISK ASSESSMENT (HRA) | Limited to lower of 100% Negotiated rate or cost per beneficiary |
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 650 Breast pumps: R6 085 |
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 610 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 CHRONIC CONDITIONS | 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 R95 040 per beneficiary and subject to the following sub-limits: Hearing Aids (reimbursed at DSP rates): R95 040 Wheelchairs for Quadriplegics: R95 040 Standard Wheelchairs: R60 620 Insulin Pumps: R62 070 Other external appliances: R20 380 (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. Prior to departure from South Africa, members are required to declare their upcoming journey to activate this coverage. 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 985 Child R12 480 |
GPs AND DENTISTS | 80% CBT Nominated Network GP for Double Network |
SPECIALISTS - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 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 - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 80% CBT (on referral from a nominated network GP or a specialist for Double Network) |
SPECTACLES AND LENSES | PPN is the DSP for Double Network Consultation: See Preventive Wellness Benefit Add ons R1 520 Single vision R1 520 OR Bifocal R4 055 OR Varifocal R6 215 AND Frames R5 585 OR Contact lenses R5 420 Lenses, frames etc 80% Optical Assistant Rates SUBJECT TO THE OVERALL DAY-TO-DAY BENEFIT LIMITS |
OVER THE COUNTER MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R2 575 per beneficiary |
HEALTH CHECK BOOST | R500 per beneficiary Not available for pharmacy benefits. |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | 80% CBT limited to: M0 R17 530 M1 R25 245 M2+ R33 995 |
DENTAL IMPLANTS | R57 750 per beneficiary for the case as a whole (facility fee, tooth implant and provider accounts) |
LASER K/EXCIMER LASER | 80% CBT limited to R6 580 per beneficiary per eye |
| MONTHLY CONTRIBUTION RATES | |||
|---|---|---|---|
| |
||
| Monthly Risk Contribution | Adult Child | R6 460 | R5 840 |
| Monthly MSA Contribution | Adult Child | R415 | R385 |
| Total Monthly Contribution | Adult Child | R6 875 | R6 225 |
View Vital Plus & Vital Network benefit option summary
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 (combined limit for in and out of hospital). Limit before PMB/CDL applies. |
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 |
INFERTILITY TREATMENT | No benefit |
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.
| CAMAF PREVENTIVE WELLNESS PROGRAMME (per Adult Beneficiary) | |
|---|---|
CAMAF PREVENTIVE WELLNESS PROGRAMME | INCLUDES: 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 945 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 405 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) |
ONE HEALTH RISK ASSESSMENT (HRA) | Limited to lower of 100% Negotiated rate or cost per beneficiary |
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 645 (subject to out of hospital overall annual limit) Breast pumps: R6 085 (subject to out of hospital overall annual limit) |
METABOLIC SCREENING FOR NEW BORN BABIES | 100% Negotiated Rate per new born baby |
ANTE-NATAL FOETAL SCANS PER PREGNANCY | No benefit |
ANTE-NATAL CLASSES | No benefit |
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 R21 000 |
|
|---|---|
OVERALL ANNUAL LIMIT | R21 000 Overall Limit per Beneficiary. Limit before PMB/CDL applies |
BASIC AND ADVANCED RADIOLOGY | 100% CBT limited to R10 500 (subject to overall annual limit) 2 Advanced scans (combined limit for in and out of hospital). Limit before PMB/CDL applies |
PATHOLOGY | 100% negotiated Rate or CBT limited to R5 250 (subject to overall annual limit). Limit before PMB/CDL applies |
POST-HOSPITALISATION | 300% CBT for attending practitioners 100% CBT for supplementary services Subject to overall annual limit |
MEDICATION AND TREATMENT FOR ADDITIONAL CHRONIC CONDITIONS | 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT. Limited to R13 650 per beneficiary. |
EXTERNAL APPLIANCES (subject to referral) | 100% NAPPI price or 100% of cost, subject to the overall external appliance limit of R21 000 AND the overall annual limit of R21 000 per beneficiary AND subject to the following sub-limits - limit before PMB/CDL applies: Hearing Aids (reimbursed at DSP rates): R21 000 Other external appliances: R11 915 NOT SUBJECT TO THE OVERALL ANNUAL LIMIT: Wheelchairs for Quadriplegics: R47 535 Standard Wheelchairs: R33 385 Insulin Pumps: R54 700 |
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. Prior to departure from South Africa, members are required to declare their upcoming journey to activate this coverage. 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 - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 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 - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | No Benefit |
SPECTACLES AND LENSES | Consultation: Part of Preventive Wellness |
OVER THE COUNTER MEDICATION | No Benefit |
HEALTH CHECK BOOST | R500 per beneficiary Not available for pharmacy benefits. |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | No Benefit |
DENTAL IMPLANTS | No Benefit |
LASER K/EXCIMER LASER | No Benefit |
| MONTHLY CONTRIBUTION RATES | |||
|---|---|---|---|
| |
||
| Monthly income as defined in the Scheme Rules | Total Monthly Contribution |
||
| R0 - R60 100 | Adult Child | R3 740 | R3 445 |
| R60 101 - R150 230 | Adult Child | R4 240 | R3 920 |
| R150 231+ | Adult Child | R4 765 | R4 380 |
View Essential Plus & Essential Network benefit option summary
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 |
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 |
INFERTILITY TREATMENT | No benefit |
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.
| CAMAF PREVENTIVE WELLNESS PROGRAMME (per Adult Beneficiary) | |
|---|---|
CAMAF PREVENTIVE WELLNESS PROGRAMME | INCLUDES: 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 945 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 545 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) |
ONE HEALTH RISK ASSESSMENT (HRA) | Limited to lower of 100% Negotiated rate or cost per beneficiary |
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 AND TREATMENT 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. Prior to departure from South Africa, members are required to declare their upcoming journey to activate this coverage. 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 - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | Subject to Medical Savings Account |
ACUTE MEDICATION | Subject to Medical Savings Account |
NON-DSP VISITS | Not applicable |
CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL | Subject to Medical Savings Account |
NURSE VISITS | Subject to Medical Savings Account |
SUPPLEMENTARY HEALTH - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | Subject to Medical Savings Account |
SPECTACLES AND LENSES | Subject to Medical Savings Account |
OVER THE COUNTER MEDICATION | Subject to Medical Savings Account |
HEALTH CHECK BOOST | R500 per beneficiary Not available for pharmacy benefits. |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | Subject to Medical Savings Account |
DENTAL IMPLANTS | Subject to Medical Savings Account |
LASER K/EXCIMER LASER | Subject to Medical Savings Account |
| MONTHLY CONTRIBUTION RATES | |||
|---|---|---|---|
| |
||
| Monthly income as defined in the Scheme Rules | Total Monthly Contribution | ||
| R0 - R150 230 | |||
| Monthly Risk Contribution | Principal Adult Child | R3 055 | R2 730 |
| Monthly MSA Contribution | Principal Adult Child | R730 | R655 |
| Total Monthly Contribution | Principal Adult Child | R3 785 | R3 385 |
| R150 231+ | |||
| Monthly Risk Contribution | Principal Adult Child | R3 740 | R3 310 |
| Monthly MSA Contribution | Principal Adult Child | R730 | R655 |
| Total Monthly Contribution | Principal Adult Child | R4 470 | R3 965 |
First Choice benefit option summary
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 R49 965 per family (combined limit for in and out of hospital). Limit before PMB/CDL applies |
PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost limited to R49 965 per family (combined limit for in and out of hospital). Limit before PMB/CDL applies |
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 |
PMB DTP TREATMENT | Medication - 100% SEP plus a dispensing fee, subject to MMAP and DSP. Consultations and procedures - as per PMB regulations |
INFERTILITY TREATMENT | No benefit |
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 |
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.
| CAMAF PREVENTIVE WELLNESS PROGRAMME (per Adult Beneficiary) | |
|---|---|
CAMAF PREVENTIVE WELLNESS PROGRAMME | INCLUDES: 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 945 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 | Refer to spectacle and lenses benefits |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, subject to MMAP, limited to R2 445 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) |
ONE HEALTH RISK ASSESSMENT (HRA) | Limited to lower of 100% Negotiated rate or cost per beneficiary |
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 | No benefit |
*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 980 Breast pumps: R5 125 |
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 375 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 845 per beneficiary. Limit before PMB/CDL applies Advanced scans: 100% CBT limited to R49 965 per family (combined limit for in and out of hospital). Limit before PMB/CDL applies |
PATHOLOGY | 100% negotiated rate or CBT limited to R9 320 per beneficiary. Limit before PMB/CDL applies |
POST-HOSPITALISATION | No benefit |
MEDICATION AND TREATMENT 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 925 per beneficiary (reimbursed at DSP rates) |
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. Prior to departure from South Africa, members are required to declare their upcoming journey to activate this coverage. 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 325 (b) Advanced Dentistry R9 060 (c) Other R4 325 (d) Specialists R13 300 Limit before PMB/CDL applies (excluding (a)) |
GPs AND DENTISTS | 80% CBT Subject to limit (c) |
SPECIALISTS - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 80% CBT Subject to limit (d) |
ACUTE MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a) |
NON-DSP VISITS | Not applicable |
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 - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 80% CBT subject to sub-limit R3 635 Subject to limit (c) |
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 R980 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 R1 005. 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 R420 AND EITHER SPECTACLES - A frame benefit of R784 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 R225 per lens or one pair of clear flat top bifocal spectacle lenses limited to R485 per lens or one pair of clear flat top Multifocal lenses limited to R850 per lens OR CONTACT LENSES - Contact Lenses to the value of R1 005. |
OVER THE COUNTER MEDICATION | 50% SEP plus a dispensing fee, subject to MMAP, limited to R2 220 per beneficiary. Subject to limit (a) |
HEALTH CHECK BOOST | R500 per beneficiary Not available for pharmacy or optometry benefits. |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | 50% CBT Subject to limit (b) dental implants excluded |
DENTAL IMPLANTS | No Benefit |
LASER K/EXCIMER LASER | No Benefit |
| MONTHLY CONTRIBUTION RATES | ||
|---|---|---|
 |
||
| Monthly income as defined in the Scheme Rules | Total Monthly Contribution | |
| R0 - R12 810 | Adult Child | R1 730 |
| R12 811 - R24 710 | Adult Child | R2 800 |
| R24 711 - R33 120 | Adult Child | R4 205 |
| R33 121 - R49 690 | Adult Child | R5 315 |
| R49 691+ | Adult Child | R5 875 |
Network Choice benefit option summary
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 | 100% CBT |
BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
RADIOLOGY IN HOSPITAL | 100% CBT 100% CBT limited to R49 965 per family (combined limit for in and out hospital). Limit before PMB/CDL applies |
PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost limited to R49 965 per family (combined limit for in and out of hospital). Limit before PMB/CDL applies |
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 |
INFERTILITY TREATMENT | No benefit |
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.
| CAMAF PREVENTIVE WELLNESS PROGRAMME (per Adult Beneficiary) | |
|---|---|
CAMAF PREVENTIVE WELLNESS PROGRAMME | INCLUDES: 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 945 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 | Refer to spectacle and lenses benefits |
IMMUNISATION AND VACCINES | SEP plus a dispensing fee, subject to MMAP, limited to R2 445 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) |
ONE HEALTH RISK ASSESSMENT (HRA) | Limited to lower of 100% Negotiated rate or cost per beneficiary |
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 | No benefit |
*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 980 Breast pumps: R5 125 |
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 375 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 845 per beneficiary. Limit before PMB/CDL applies Advanced scans: 100% CBT limited to R49 965 per family (in and out of hospital combined and on referral by a nominated network GP or specialist). Limit before PMB/CDL applies |
PATHOLOGY | Referred by nominated network GP or specialist, 100% negotiated rate or CBT, limited to R9 320 per beneficiary. Limit before PMB/CDL applies |
POST-HOSPITALISATION | No benefit |
MEDICATION AND TREATMENT 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 925 per beneficiary (reimbursed at DSP rates) 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. Prior to departure from South Africa, members are required to declare their upcoming journey to activate this coverage. 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 325 (b) Advanced Dentistry R9 060 (c) Other R4 325 (d) Specialists R13 300 Limit before PMB/CDL applies (excluding (a)) |
GPs AND DENTISTS | 100% negotiated rate subject to sublimit (c) - Nominated Network GP only |
SPECIALISTS - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 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 845 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 - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS | 100% CBT limited to R3 635 per beneficiary on referral from a nominated network GP or from a Specialist. Subject to limit (c) |
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 R980 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 R1 005. 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 R420 AND EITHER SPECTACLES - A frame benefit of R784 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 R225 per lens or one pair of clear flat top bifocal spectacle lenses limited to R485 per lens or one pair of clear flat top Multifocal lenses limited to R850 per lens OR CONTACT LENSES - Contact Lenses to the value of R1 005. |
OVER THE COUNTER MEDICATION | 50% SEP plus a dispensing fee, subject to MMAP, limited to R2 220 per beneficiary. Subject to limit (a) |
HEALTH CHECK BOOST | R500 per beneficiary Not available for pharmacy or optometry benefits. |
| BENEFIT SPECIFIC LIMITS | |
ADVANCED DENTISTRY | 100% of CBT Subject to limit (b) dental implants excluded |
DENTAL IMPLANTS | No Benefit |
LASER K/EXCIMER LASER | No Benefit |
| MONTHLY CONTRIBUTION RATES | ||
|---|---|---|
 |
||
| Monthly income as defined in the Scheme Rules | Total Monthly Contribution | |
| R0 - R20 000 | Principal Adult 1st Child (rest are free) | R1 850 |
| R20 001 - R24 710 | Principal Adult 1st Child (rest are free) | R2 465 |
| R24 711 - R33 120 | Principal Adult 1st Child (rest are free) | R2 940 |
| R33 121 - R49 690 | Principal Adult Child | R3 585 |
| R49 691+ | Principal Adult Child | R4 855 |
Monthly Risk Contribution Adult R9 885 Monthly MSA Contribution Adult R650 Total Monthly Contribution Adult R10 535 Monthly Risk Contribution Adult R8 875 Monthly MSA Contribution Adult R590 Total Monthly Contribution Adult R9 465 | Monthly Risk Contribution Adult R6 460 Monthly MSA Contribution Adult R415 Total Monthly Contribution Adult R6 875 Monthly Risk Contribution Adult R5 840 Monthly MSA Contribution Adult R385 Total Monthly Contribution Adult R6 225 | Total monthly contribution for a monthly income ¹ of R0 - R60 100 Adult R3 740 Total monthly contribution for a monthly income ¹ of R60 101 - R150 230 Adult R4 240 Total monthly contribution for a monthly income ¹ of R150 231+ Adult R4 765 Total monthly contribution for a monthly income ¹ of R0 - R60 100 Adult R3 445 Total monthly contribution for a monthly income ¹ of R60 101 - R150 230 Adult R3 920 Total monthly contribution for a monthly income ¹ of R150 231+ Adult R4 380 | R0 - R150 230 ¹ Monthly Risk Contribution Principal R3 055 Monthly MSA Contribution Principal R730 Total Monthly Contribution Principal R3 785 R150 231+ ¹ Monthly Risk Contribution Principal R3 740 Monthly MSA Contribution Principal R730 Total Monthly Contribution Principal R4 470 R0 - R150 230 ¹ Monthly Risk Contribution Principal R2 730 Monthly MSA Contribution Principal R655 Total Monthly Contribution Principal R3 385 R150 231+ ¹ Monthly Risk Contribution Principal R3 310 Monthly MSA Contribution Principal R655 Total Monthly Contribution Principal R3 965 | Total monthly contribution for a monthly income ¹ of R0 - R12 810 Adult R1 730 Total monthly contribution for a monthly income ¹ of R12 811 - R24 710 Adult R2 800 Total monthly contribution for a monthly income ¹ of R24 711 - R33 120 Adult R4 205 Total monthly contribution for a monthly income ¹ of R33 121 - R49 690 Adult R5 315 Total monthly contribution for a monthly income ¹ of R49 691+ Adult R5 875 | Total monthly contribution for a monthly income ¹ of R0 - R20 000 Principal R1 850 Total monthly contribution for a monthly income ¹ of R20 001 - R24 710 Principal R2 465 Total monthly contribution for a monthly income ¹ of R24 711 - R33 120 Principal R2 940 Total monthly contribution for a monthly income ¹ of R33 121 - R49 690 Principal R3 585 Total monthly contribution for a monthly income ¹ of R49 691+ Principal R4 855 |
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. |
| LIMIT BEFORE PMB/CDL | CDL, DTP, PMB and non-PMB claims will pay from the benefit limit. If the limit is depleted PMB claims will be funded in line with Scheme protocols and the use of DSPs where applicable, and the remaining benefits for chronic conditions will pay per the approved treatment plan. |
| 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
 |
Network Hospital: DSP hospital group is Netcare – No limits |
 |
Attending Doctors: 100% CBT only at DSP |
 |
27 Chronic Conditions: medication and consultations. |
 |
Radiology Advanced scans limited to R49 965 per family (combined limit for in and out of hospital.) Limit before PMB/CDL applies. R5 845 per beneficiary for basic radiology (on referral by nominated GP or specialist for out of hospital) |
 |
Screening Benefits: PSA, Pap Smear, Mammogram |
 |
Vaccines |
 |
Any Private Hospital – No limits |
 |
Attending Doctors and Specialists: 100% CBT |
 |
27 Chronic Conditions: medication and consultations. |
 |
Radiology Advanced scans limited to R49 965 per family (combined limit for in and out of hospital.) Limit before PMB/CDL applies. R5 845 per beneficiary for basic radiology |
 |
Screening Benefits: PSA, Pap Smear, Mammogram |
 |
80% of GP, Specialists, Dental, Optometry, Checkups, ECG, Vaccines |
 |
Essential Plus: Any Private Hospital – No limits Essential Network: DSP hospitals are Life Healthcare and Netcare – No limits 20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies. |
 |
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 |
 |
Vital Plus: Any Private Hospital – No limits Vital Network: DSP hospitals are Life Healthcare and Netcare – No limits 20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies. |
 |
Attending Doctors and Specialists: 300% of CBT |
 |
60 Chronic Conditions: Medication and consultations. Covers the medication and necessary consultations and procedures |
 |
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 (DSP is HearConnect), breast pump, baby sleep monitor, Insulin pump |
 |
Checkups and Vaccines: GP, Specialist, Dental, Optometry, ECG |
 |
Double Plus: Any Private Hospital – No limits Double Network: DSP hospitals are Life Healthcare and Netcare – No limits 20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies. |
 |
Attending Doctors and Specialists: 300% CBT |
 |
64 Chronic Conditions Medication and Consultations. Biological medication for non-PMB conditions is available in exceptional cases on Alliance options, a 20% co-payment will apply (not on biologics approved for CDL conditions) |
 |
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 (DSP is HearConnect), 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 R83 050 per family |
 |
Alliance Plus: Any Private Hospital – No limits. Private wards for childbirth confinements (subject to availability and pre-authorisation) Alliance Network: DSP hospitals are Life Healthcare and Netcare – No limits, private wards for childbirth confinements (subject to availability and pre-authorisation) (20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies) |
 |
Attending Doctors and Specialists: 300% CBT |
 |
65 Chronic Conditions medication and consultations. Biological medication for non-PMB conditions is available in exceptional cases on Alliance options, a 20% co-payment will apply (not on biologics approved for CDL conditions) |
 |
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 (DSP is HearConnect), 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 R117 760 per family |
|
Network Hospital: DSP hospital group is Netcare – No limits |
|
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 |
|
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 |
|
Essential Plus: Any Private Hospital – No limits Essential Network: DSP hospitals are Life Healthcare and Netcare – No limits 20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies. |
|
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 |
|
Vital Plus: Any Private Hospital – No limits Vital Network: DSP hospitals are Life Healthcare and Netcare – No limits 20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies. |
|
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 (DSP is HearConnect), breast pump, baby sleep monitor, Insulin pump |
|
Checkups and Vaccines: GP, Specialist, Dental, Optometry, ECG |
|
Double Plus: Any Private Hospital – No limits Double Network: DSP hospitals are Life Healthcare and Netcare – No limits 20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies. |
|
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 (DSP is HearConnect), 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 |
|
Alliance Plus: Any Private Hospital – No limits. Private wards for childbirth confinements (subject to availability) Alliance Network: DSP hospitals are Life Healthcare and Netcare – No limits, private wards for childbirth confinements (subject to availability) (20% co-payment applies for utilisation of non-DSP hospitals for non-emergencies) |
|
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 (DSP is HearConnect), 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 |
