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Additional Information
| ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS, MEDICAL AND SURGICAL PROCEDURES INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | Up to 100% CBT, 100% CBT |
|---|---|
| SUPPLEMENTARY HEALTHCARE IN HOSPITAL (EG. 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 limited to R38 000 per family |
| PATHOLOGY IN HOSPITAL | 100% CBT |
| INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost limited to R38 000 per family, Exclusions: cochlear implants |
| HOME NURSING UP TO 21 DAYS, SUBJECT TO PRE-AUTHORISATION (PROFESSIONAL NURSES ONLY; FRAIL CARE EXCLUDED) | 100% CBT (in lieu of hospitalisation only) |
| 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 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 (Network Doctor only) |
| 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 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 | Refer to spectacle and lenses benefits |
| IMMUNISATION AND VACCINES (COST OF IMMUNISATION AND VACCINE ONLY) | SEP plus a dispensing fee, subject to MMAP, limited to R1 852 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 |
| 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 265, Breast pumps: R3 900 |
| 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 limit (c) of Annual Overall Day-to-Day Benefit Limit |
| ANTE-NATAL CLASSES | 80% CBT subjects to sub-limit R1 050 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. |
| 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 | Basic Radiology: Referrals by DSP or specialist, 100% CBT limited to R4 440 per beneficiary, Advanced scans: 100% CBT limited to R38 000 per family (on referral by DSP or specialist) |
| PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER, PRE-AUTHORISATION REQUIRED FOR ADVANCED PATHOLOGY | Referred by DSP or specialist, 100% Negotiated Rate, limited to R7 090 per beneficiary |
| MEDICATION 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 & 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, limited to R6 790 per beneficiary and subject to DSP or Specialist referral |
| 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 limit: Beneficiary specific limits:, (a) Medicines R3 290, (b) Advanced Dentistry R6 890, (c) Other R3 290, (d) Specialists R10 120 |
| GPs AND DENTISTS DENTAL X-RAYS PERFORMED BY DENTISTS, CONSULTATIONS AND PROCEDURES PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY | 100% negotiated rate, subject to sublimit (c) – Network GP only |
| SPECIALISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS | 100% CBT, Subject to limit (d) (on referral from a network GP only) |
| ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS | 100% SEP plus a dispensing fee, subject to MMAP., Subject to limit (a) (on referral from a network GP only) |
| NON-DSP VISITS TO DOCTOR’S ROOMS | One non-network or non-nominated visit per beneficiary or two per family, 20% co-payment |
| CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATION WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT | One casualty visit per family (facility fee, consumed meds and materials). Limited to R 1 580 |
| NURSE VISITS | 100% CBT subject to limit (c) |
| SUPPLEMENTARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY | 100% CBT limited to R2 760 per beneficiary on referral from DSP or from a Specialist., Subject to limit (c) |
| ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES | 100% of CBT, Subject to limit (b) dental implants excluded |
| OVER THE COUNTER MEDICATION | 50% SEP plus a dispensing fee, subject to MMAP, limited to R1 690 per beneficiary., Subject to limit (a) |
| SPECTACLES AND LENSES FROM OPTOMETRIST ONLY; ANNUAL BENEFIT, UNLESS OTHERWISE STATED | 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 R750 off any alternative frame and/or lens enhancements and, one pair of lenses: either One pair of Clear A quity Single Vision; Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR, CONTACT LENSES – Contact lenses to the value of R840., 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 R300 AND, EITHER SPECTACLES – A frame benefit of R600 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 R175 per lens or, one pair of clear flat top bifocal spectacle lenses limited to R410 per lens or, one pair of clear flat top Multifocal lenses limited to R710 per lens, OR CONTACT LENSES – Contact Lenses to the value of R840., The benefit PER BENEFICIARY at a PPN provider would be as follows: |
| RATES | 1st Child (rest are free) R725, 1st Child (rest are free) R891, Adult R1 394, Adult R1 582, Adult R1 837, Adult R2 544, Child R1 182, Child R1 548, Income Category R0 – R18 960, Income Category R18 961 – R25 420, Income Category R25 421 – R38 140, Income Category R38 141+, Principal R1 667, Principal R1 982, Principal R2 372, Principal R3 153, Monthly income based on Total Cost to Company of Principal Member |
