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ALLIANCE
Additional Information
| ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS, MEDICAL AND SURGICAL PROCEDURES INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | Up to 300% CBT, 300% CBT |
|---|---|
| SUPPLEMENTARY HEALTHCARE IN HOSPITAL (EG. PHYSIOTHERAPY AND PSYCHOTHERAPY) | 100% CBT |
| BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) | 100% of cost |
| RADIOLOGY IN HOSPITAL | 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 R89 600 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 ICON Enhanced benefits apply. |
| CAMAF PREVENTIVE WELLNESS PROGRAMME PER ADULT BENEFICIARY | INCLUDES: Free health risk assessment at Clicks, Dischem or Pick n Pay pharmacy |
| 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 R13 040 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 | |
| ONE OPTOMETRIST CONSULTATION | 100% Optical Assistant Rates |
| IMMUNISATION AND VACCINES (COST OF IMMUNISATION AND VACCINE ONLY) | SEP plus a dispensing fee, limited to R5 565 per beneficiary |
| CERVICAL CANCER VACCINE (HPV) (COST OF VACCINE ONLY) | Females between 9 and 16 years of age (SEP plus dispensing fee) |
| ONE HIV VCT TEST | 100% CBT per beneficiary |
| ONE MELANOMA SCREENING | 100% CBT per adult beneficiary |
| HOSPITAL ACCOMMODATION (IN HOSPITAL) 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: R2 830, Breast pumps: R4 630 |
| 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 R2 707 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 |
| PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER, PRE-AUTHORISATION REQUIRED FOR ADVANCED PATHOLOGY | 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 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 & OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE; CPAP (subject to pre-authorisation) - 3 YEAR CYCLE; HEARING AIDS (subject to pre-authorisation) - 1 CLA | 100% NAPPI price or 100% of cost, subject to the overall limit of R90 400 per beneficiary and subject to the following sub-limits:, Hearing Aids: R90 400, Insulin Pumps: R54 000, Other external appliances: R17 900, Standard Wheelchairs: R54 000, Wheelchairs for Quadriplegics: R90 400 |
| 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. | R10 million per beneficiary per journey for emergency medical costs while you travel outside South Africa., This cover is for a period of 90 days from your departure from South Africa. Cover for pre-existing conditions is limited to R150,000 unless additional cover is arranged., The cover is available to members who are not older than 80 years of age. |
| 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 R35 100, Child R21 900 |
| GPs AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY | 80% CBT |
| SPECIALISTS 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 | Not applicable |
| CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT | 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 |
| ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES | 80% CBT limited to:, M0 R17 900, M1 R26 800, M2+ R32 200 |
| OVER THE COUNTER MEDICATION | 80% SEP plus a dispensing fee, subject to MMAP, co-payment from MSA, limited to R4 500 per beneficiary |
| LASER K/EXCIMER LASER NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS | 80% CBT limited to R13 550 per beneficiary per eye |
| SPECTACLES AND LENSES FROM OPTOMETRIST ONLY; ANNUAL BENEFIT, UNLESS OTHERWISE STATED | Consultation: See Preventative Wellness Benefit, Add ons R1 760, Single vision R1 760 OR, Bifocal R3 520 OR, Varifocal R5 300 AND, Frames R7 900 OR, Contact lenses R7 680, Lenses, frames etc 80% Optical Assistant Rates |
| RATES | Adult R6 116, Adult R6 726, Adult R610, Child R280, Child R3 325, Child R3 605, Monthly Risk Contribution, Monthly MSA Contribution, Total Monthly Contribution |
