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ESSENTIAL NETWORK
Additional Information
| HOSPITAL ACCOMMODATION (IN HOSPITAL) INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | 100% of Negotiated Rate in general ward and specialised units., 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 | 200% 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, Exclusions: cochlear implants |
| 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% DSP Tariff |
| MEDICATION IN HOSPITAL | 100% SEP plus dispensing fee |
| TTO MEDICATION UP TO ONE WEEK’S SUPPLY | 100% SEP plus dispensing fee |
| SUBSTANCE ABUSE | PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days |
| CHRONIC PMB CDL MEDICATION AND TREATMENT - SUBJECT TO PRE-AUTHORISATION, PROTOCOLS AND FORMULARIES 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 – 100% DSP Tariff, The DSP is the ICON network., The ICON Essential 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 R2 545 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 | 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 Annual Overall Day-to-Day Limit |
| 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. |
| OVERALL ANNUAL LIMIT FOR OUT OF HOSITAL BENEFITS OTHER THAN DAY TO DAY BENEFITS | Subject to Medical Savings Account |
| 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 | Subject to Medical Savings Account |
| PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER | Subject to Medical Savings Account |
| POST-HOSPITALISATION CONSULTATIONS AND TREATMENT UP TO 90 DAYS | Subject to Medical Savings Account |
| MEDICATION AND TREATMENT FOR ADDITIONAL CHRONIC CONDITIONS (SUBJECT TO PRE-AUTHORISATION) REFER TO ADDITIONAL CHRONIC CONDITIONS LIST | Depression only. 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 | Subject to Medical Savings Account |
| 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 | Limited to funds available in the beneficiary’s Medical Savings Account |
| GPs AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY | Subject to Medical Savings Account |
| SPECIALISTS - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS | Subject to Medical Savings Account |
| ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS | Subject to Medical Savings Account |
| NON-DSP VISITS TO DOCTOR’S ROOMS | 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 AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY | Subject to Medical Savings Account |
| 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 | Subject to Medical Savings Account |
| OVER THE COUNTER MEDICATION | Subject to Medical Savings Account |
| 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 | Subject to Medical Savings Account |
| DENTAL IMPLANTS | Subject to Medical Savings Account |
| 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 | Subject to Medical Savings Account |
| RATES | Monthly income: R0 – R150 230, Monthly Risk Contribution, Principal R2 730, Adult R2 160, Child R1 265, Monthly MSA Contribution, Principal R655, Adult R520, Child R315, Total Monthly Contribution, Monthly income: R150 231+, Monthly Risk Contribution, Principal R3 385, Adult R2 680, Child R1 580, Principal R3 310, Adult R2 620, Child R1 535, Monthly MSA Contribution, Principal R655, Adult R520, Child R315, Total Monthly Contribution, Principal R3 965, Adult R3 140, Child R1 850 |
| BenefitOptionWizard: Hospitals | Hospitals, Network Hospital |
| BenefitOptionWizard: Doctors' Rates | Doctors' Rates (In Hospital), 200% CBT |
| BenefitOptionWizard: Chronic Conditions | Chronic Conditions, Standard List of Conditions |
| BenefitOptionWizard: Radiology & Pathology | Radiology & Pathology, Unlimited In, Limited Out of Hospital |
| BenefitOptionWizard: Day to Day | Day to Day, None |
| BenefitOptionWizard: Medical Savings | Medical Savings Account, With MSA |
| BenefitOptionWizard: Post-hospital Cover | Post-hospital Cover, Without Cover |
