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ALLIANCE NETWORK
Additional Information
| HOSPITAL ACCOMMODATION (IN HOSPITAL) 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 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 |
| SUPPLEMENTARY HEALTHCARE IN HOSPITAL (EG. PHYSIOTHERAPY AND PSYCHOTHERAPY) | 100% CBT |
| BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
| RADIOLOGY IN HOSPITAL | 100% CBT |
| ADVANCED SCANS (MRI/CT/PET) SUBJECT TO PRE-AUTHORISATION | 100% CBT |
| PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
| INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost |
| HOME NURSING UP TO 21 DAYS, SUBJECT TO PRE-AUTHORISATION (PROFESSIONAL NURSES ONLY; FRAIL CARE EXCLUDED) | 100% CBT |
| STEP-DOWN/PHYSICAL REHABILITATION APPROVED FACILITIES ONLY, UP TO 90 DAYS (SUBJECT TO PRE-AUTHORISATION) | 100% Negotiated Rate |
| MEDICATION IN HOSPITAL | 100% SEP plus dispensing fee |
| TTO MEDICATION UP TO ONE WEEK’S SUPPLY | 100% SEP plus dispensing fee |
| INFERTILITY TREATMENT | Treatment limited to R106 811 per family |
| SUBSTANCE ABUSE | PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days |
| CHRONIC PMB CDL MEDICATION AND TREATMENT - SUBJECT TO PRE-AUTHORISATION, PROTOCOLS AND FORMULARIES REFER TO CHRONIC DISEASE LIST | 100% SEP plus a dispensing fee, subject to RP and DSP, Consultations and procedures – as per PMB regulations (on referral from a nominated network GP) |
| PMB DTP TREATMENT OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF CONDITION AND PRE-AUTHORISATION | Medication – 100% SEP plus a dispensing fee, subject to MMAP and DSP, Consultations and procedures – as per PMB regulations (on referral from a nominated network GP) |
| ONCOLOGY SUBJECT TO PRE-AUTHORISATION AND ICON PROTOCOLS | Medication – 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures – at 300% CBT, The DSP is the ICON network. The ICON Enhanced protocols apply. |
| CAMAF PREVENTIVE WELLNESS PROGRAMME PER ADULT BENEFICIARY | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy and free Online Wellness Club |
| ONE GP CONSULTATION ONLY *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP ONLY | 100% CBT per beneficiary (Nominated Network GP) |
| ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP ONLY. GYNAECOLOGISTS, UROLOGISTS, OR SPECIALIST PHYSICIANS FOR BENEFICIARIES OVER 18. PAEDIATRICIANS FOR UNDER 18's | 100% CBT per beneficiary |
| PSYCHOTHERAPY | 100% CBT limited to R16 274 per beneficiary |
| ONE DIETICIAN CONSULTATION | 100% CBT per beneficiary |
| ONE DENTISTRY CONSULTATION GENERAL CHECKUP ONLY - excludes consumables | 100% CBT per beneficiary |
| ONE ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP ONLY | 100% CBT per adult beneficiary |
| ONE OPTOMETRIST CONSULTATION | PPN Rates |
| IMMUNISATION AND VACCINES (COST OF IMMUNISATION AND VACCINE ONLY) | SEP plus a dispensing fee, limited to R6 547 per beneficiary |
| CERVICAL CANCER VACCINE (HPV) (COST OF VACCINE ONLY) | Females between 9 and 45 years of age (SEP plus dispensing fee) |
| HUMAN PAPILLOMA VIRUS (HPV) VACCINE (COST OF VACCINE ONLY) | Females between 9 and 45 years of age., Males between 9 and 26 years of age., Includes initial vaccination and two follow-up booster vaccinations, where applicable., (SEP plus dispensing fee) |
| PSA SCREENING | Males older than 40 years of age (100% Negotiated Rate or CBT) |
| 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 |
| HOSPITAL ACCOMMODATION (MATERNITY) INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | See In Hospital and Prescribed Minimum Benefits above |
| EXTERNAL APPLIANCES SUBJECT TO OVERALL EXTERNAL APPLIANCES LIMIT: BREAST PUMPS & APNOEA MONITORS – 3 MONTHS PRIOR TO EXPECTED DUE DATE & WITHIN 6 MONTHS AFTER BIRTH OF BABY. SUBJECT TO REGISTRATION | Baby Apnoea Monitors: R3 372, Breast pumps: R5 517 |
| METABOLIC SCREENING FOR NEW BORN BABIES | 100% Negotiated Rate per new born baby |
| ANTE-NATAL FOETAL SCANS PER PREGNANCY | 6 scans at 80% CBT, Subject to Annual Overall Day-to-Day Limit |
| ANTE-NATAL CLASSES | 80% CBT limited to R3 227 per pregnancy, Subject to Annual Overall Day-to-Day Limit |
| UMBLICAL STEM CELL HARVESTING | Negotiated discount with Cryo-Save., Note: Please note that CAMAF does not cover expenses related to cord blood stem cell harvesting, testing and storage as this is not treatment for a specific medical condition., The cash discount that is offered is passed directly on to you and is not paid from your health plan benefits. |
| BASIC AND ADVANCED RADIOLOGY OUT OF HOSPITAL MUST BE PERFORMED BY A REGISTERED RADIOLOGIST, ON REFERRAL FROM MEDICAL PRACTITIONER ONLY. ADVANCED SCANS (MRI/CT/PET) SUBJECT TO PRE-AUTHORISATION | 100% CBT (on referral from a nominated network GP or a specialist) |
| PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER | 100% Negotiated Rate or CBT (on referral from a nominated network GP or a specialist) |
| POST-HOSPITALISATION CONSULTATIONS AND TREATMENT UP TO 90 DAYS | 300% CBT for attending practitioners, 100% CBT for supplementary services |
| MEDICATION AND TREATMENT FOR ADDITIONAL CHRONIC CONDITIONS (SUBJECT TO PRE-AUTHORISATION) REFER TO ADDITIONAL CHRONIC CONDITIONS LIST | 100% SEP plus a dispensing fee, subject to RP and DSP, Consultations 100% CBT, (on referral from a nominated network GP; medication claims will not be paid if non-nominated network GP is used) |
| EXTERNAL APPLIANCES (subject to referral); IN & OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE; CPAP (subject to pre-authorisation) - 3 YEAR CYCLE; HEARING AIDS (subject to pre-authorisation) - 1 CLA | (on referral from a nominated network GP or a specialist), 100% NAPPI price or 100% of cost, subject to the overall limit of R107 829 per beneficiary and subject to the following sub-limits:, Hearing Aids: R107 829, Wheelchairs for Quadriplegics: R107 829, Standard Wheelchairs: R64 337, Insulin Pumps: R64 337, Other external appliances: R21 348 |
| INTERNATIONAL TRAVEL COVER PROVIDED BY TRAVEL INSURANCE CONSULTANTS (TIC) AND SUBJECT TO THEIR POLICY REQUIREMENTS. ARRANGE COVER PRIOR TO YOUR TRAVEL. VISIT OUR WEBSITE FOR FULL DETAILS. | R5 million per beneficiary per journey for emergency unforeseen and unexpected medical costs while you travel outside of South Africa, and you have declared your trip before departing., This cover is for a maximum period of 90 days from your departure from South Africa and ceases upon your return to South Africa., Refer to Travel Letter Wording. |
| NETCARE 911 EMERGENCY SERVICES | Unlimited, Subject to Netcare 911 authorisation |
| DAY-TO-DAY BENEFITS: BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT | Annual Overall Limits, Adult R41 870, Child R26 076 |
| GPs AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY | 80% CBT Nominated Network GP |
| SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS | 80% CBT (on referral from a nominated network GP) |
| ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS | 80% SEP plus dispensing fee, subject to MMAP, co-payment from MSA (on referral from a nominated network GP) |
| NON-DSP VISITS TO DOCTOR’S ROOMS | One visit per beneficiary 80% CBT for non-network or non-nominated GP |
| CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL | 80% CBT |
| NURSE VISITS | 80% CBT up to 21 days |
| SUPPLEMENTARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY | 80% CBT (on referral from a nominated network GP or from a specialist) |
| ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES | 80% CBT limited to:, M0 R21 348, M1 R31 906, M2+ R38 478 |
| OVER THE COUNTER MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP, copayment from MSA, limited to R5 269 per beneficiary |
| LASER K/EXCIMER LASER NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS | 80% CBT limited to R16 165 per beneficiary per eye |
| SPECTACLES & LENSES FROM OPTOMETRIST ONLY; ANNUAL BENEFIT, UNLESS OTHERWISE STATED; WHERE PPN IS INDICATED AS THE DSP, PPN RATES & TARIFFS WILL APPLY. FOR ALL OTHER OPTIONS, OPTICAL ASSISTANT RATES | Consultation: See Preventive Wellness Benefit, Add ons R2 094, Single vision R2 094 OR, Bifocal R4 198 OR, Varifocal R6 318 AND, Frames R9 423 OR, Contact lenses R9 158, Lenses, frames etc 80% PPN Rates |
| RATES | Monthly Risk Contribution, Adult R7 093, Child R3 835, Monthly MSA Contribution, Adult R565, Child R260, Total Monthly Contribution, Adult R7 658, Child R4 095 |
