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ALLIANCE PLUS
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). |
|---|---|
| ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS, MEDICAL AND SURGICAL PROCEDURES INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | 300% CBT |
| SUPPLEMENTARY HEALTHCARE IN HOSPITAL (e.g. 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 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 REFER TO CHRONIC DISEASE LIST | 100% SEP plus a dispensing fee, subject to RP and DSP, Consultations and procedures – as per PMB regulations |
| PMB DTP TREATMENT OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF CONDITION AND PRE-AUTHORISATION | Medication – 100% SEP plus a dispensing fee, subject to MMAP and DSP, Consultations and procedures – as per PMB regulations |
| ONCOLOGY SUBJECT TO PRE-AUTHORISATION AND ICON PROTOCOLS | Medication – 100% SEP plus a dispensing fee, subject to RP and DSP. Consultations and procedures – at 300% CBT, The DSP is the ICON network. The ICON Enhanced protocols apply. |
| CAMAF PREVENTIVE WELLNESS PROGRAMME PER ADULT BENEFICIARY | INCLUDES: Free Online Wellness Club. |
| ONE GP CONSULTATION ONLY *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP ONLY | 100% CBT per beneficiary |
| ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP ONLY. GYNAECOLOGISTS, UROLOGISTS, OR SPECIALIST PHYSICIANS FOR BENEFICIARIES OVER 18. PAEDIATRICIANS FOR UNDER 18's | 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) *ICD 10 CODE SPECIFIC TO GENERAL CHECKUP ONLY | 100% CBT per adult beneficiary |
| ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
| IMMUNISATION AND VACCINES (COST OF IMMUNISATION AND VACCINE ONLY) | SEP plus a dispensing fee, limited to R7 220 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) |
| ONE HEALTH RISK ASSESSMENT (HRA) TO BE DONE AT NETWORK PHARMACY | 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 |
| 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 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. |
| OVERALL ANNUAL LIMIT FOR OUT OF HOSITAL BENEFITS OTHER THAN DAY TO DAY BENEFITS | Unlimited, limits and sub-limits per benefit category applies where applicable |
| BASIC AND ADVANCED RADIOLOGY OUT OF HOSPITAL MUST BE PERFORMED BY A REGISTERED RADIOLOGIST, ON REFERRAL FROM MEDICAL PRACTITIONER ONLY. ADVANCED SCANS (MRI/CT/PET) SUBJECT TO PRE-AUTHORISATION | 100% CBT |
| PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER | 100% Negotiated Rate or CBT |
| POST-HOSPITALISATION CONSULTATIONS AND TREATMENT UP TO 90 DAYS | 300% CBT for attending practitioners, 100% CBT for supplementary services |
| MEDICATION AND TREATMENT FOR ADDITIONAL CHRONIC CONDITIONS (SUBJECT TO PRE-AUTHORISATION) REFER TO ADDITIONAL CHRONIC CONDITIONS LIST | 100% SEP plus a dispensing fee, subject to RP and DSP, Consultations 100% CBT |
| EXTERNAL APPLIANCES (subject to referral) IN AND OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE CPAP (subject to pre-authorisation) - 3 YEAR CYCLE HEARING AIDS (subject to pre-authorisation and reimbursed at DSP rates. Benefit is for a 3 year cycle). Maintenance is included. The DSP for audiology consultations and obtaining a Hearing Aid is the hearConnect network for ALL OPTIONS. Co-payments will apply if the DSP is not used - 1 CLAIM PER 3 YEAR CYCLE FOR OVER 16 YEARS OF AGE YOUNGER THAN 16 YEARS OF AGE - 18 MONTH CYCLE WHEELCHAIRS - 3 YEAR CYCLE INSULIN PUMPS (subject to pre-authorisation and DSP) - 4 YEAR CYCLE | 100% NAPPI price or 100% of cost, subject to the overall 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 |
| INTERNATIONAL TRAVEL COVER TRAVEL LETTERS TO BE OBTAINED FROM SANTAM TRAVEL INSURANCE AND SUBJECT TO THE LIMITATIONS AS SET OUT IN THE TRAVEL LETTER. ARRANGE COVER PRIOR TO TRAVELLING. 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. 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 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 R46 160, Child R28 750 |
| GPs AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY | 80% CBT |
| SPECIALISTS - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS | 80% CBT |
| ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS | 80% SEP plus dispensing fee, subject to MMAP, co-payment from MSA |
| NON-DSP VISITS TO DOCTOR’S ROOMS | One visit per beneficiary 80% CBT |
| 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 AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY | 80% CBT |
| SPECTACLES AND LENSES FROM OPTOMETRIST ONLY ANNUAL BENEFIT, UNLESS OTHERWISE STATED WHERE PPN IS INDICATED AS THE DSP, THE PPN RATES AND TARIFFS WILL APPLY. FOR ALL OTHER OPTIONS, OPTICAL ASSISTANT RATES WILL APPLY | Consultation: 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 DAY-TO-DAY TOP UP BENEFIT ((ALLOCATED ONCE ALL 3 REQUIRED SCREENINGS ARE COMPLETED IN THE SAME BENEFIT YEAR). THE BENEFIT IS NON-TRANSFERABLE, DOES NOT ROLL OVER, AND IS APPLIED PER BENEFICIARY PER BENEFIT YEAR. | R500 per beneficiary, Not available for pharmacy or optometry benefits. |
| ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES | 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 BENEFIT NOT AVAILABLE IF SPECTACLES OR CONTACT LENSES CLAIMED IN THE PREVIOUS 12 MONTHS. IF LASER K BENEFIT IS UTILISED, NO SPECTACLE AND CONTACT LENSE BENEFIT FOR 2 YEARS | 80% CBT limited to R17 825 per beneficiary per eye |
| RATES | Monthly Risk Contribution, Adult R9 885, Child R5 205, Monthly MSA Contribution, Adult R650, Child R300, Total Monthly Contribution, Adult R10 535, Child R5 505 |
| BenefitOptionWizard: Hospitals | Hospitals, Any Hospital |
| BenefitOptionWizard: Doctors' Rates | Doctors' Rates (In Hospital), 300% CBT |
| BenefitOptionWizard: Chronic Conditions | Chronic Conditions, Extended List of Conditions |
| BenefitOptionWizard: Radiology & Pathology | Radiology & Pathology, Unlimited In/Out of Hospital |
| BenefitOptionWizard: Day to Day | Day to Day, Comprehensive |
| BenefitOptionWizard: Medical Savings | Medical Savings Account, With MSA |
| BenefitOptionWizard: Post-hospital Cover | Post-hospital Cover, With Cover |
