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Additional Information
| HOSPITAL ACCOMMODATION (IN HOSPITAL) INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | 100% DSP tariff as per protocols., The DSP hospital group is Netcare. |
|---|---|
| ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS, MEDICAL AND SURGICAL PROCEDURES INCLUDING CHILDBIRTH CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION | 100% 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 limited to R49 965 per family (combined limit for in and out hospital), Limit before PMB/CDL applies |
| PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
| INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost limited to R49 965 per family (combined limit for in and out of hospital), Limit before PMB/CDL applies |
| 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 |
| INFERTILITY TREATMENT | No benefit |
| 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 – 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 (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 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 | 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 R2 445 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 |
| 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: R2 980, Breast pumps: R5 125 |
| 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 the Advanced Scans limit |
| ANTE-NATAL CLASSES | 80% CBT subject to sub-limit R1 375 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. |
| 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 | Basic Radiology: Referrals by nominated network GP or specialist, 100% CBT limited to R5 845 per beneficiary. Limit before PMB/CDL applies, Advanced scans: 100% CBT limited to R49 965 per family (in and out of hospital combined and on referral by a nominated network GP or specialist). Limit before PMB/CDL applies |
| PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER | Referred by nominated network GP or specialist, 100% negotiated rate or CBT, limited to R9 320 per beneficiary. Limit before PMB/CDL applies |
| 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, (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 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, limited to R8 925 per beneficiary (reimbursed at DSP rates) and subject to a nominated network GP or Specialist referral |
| 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 limit: Beneficiary specific limits:, (a) Medicines R4 325, (b) Advanced Dentistry R9 060, (c) Other R4 325, (d) Specialists R13 300, Limit before PMB/CDL applies (excluding (a)) |
| 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) – Nominated Network GP only |
| SPECIALISTS - NOMINATED NETWORK GP REFERRAL NOT OLDER THAN 12 MONTHS FOR NETWORK OPTIONS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS | 100% CBT, Subject to limit (d) (on referral from a nominated 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 nominated network GP only) |
| NON-DSP VISITS TO DOCTOR’S ROOMS | Both the non-nominated GP visit and casualty treatment is limit to R1 845 per family, One non-network or non-nominated GP visit per beneficiary (including casualty and GP). 20% co-payment AND Casualty visits (facility fee, consumed meds and materials only) |
| NURSE VISITS | 100% CBT subject to limit (c) |
| 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 | 100% CBT limited to R3 635 per beneficiary on referral from a nominated network GP or from a Specialist., Subject to limit (c) |
| 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 | The benefit PER BENEFICIARY at a PPN provider would be as follows:, 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 R980 off any alternative frame and/or lens enhancements and one pair of lenses: either One pair of Clear Aquity Single Vision; Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES – Contact lenses to the value of R1 005., 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 R420 AND EITHER SPECTACLES – A frame benefit of R784 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 R225 per lens or one pair of clear flat top bifocal spectacle lenses limited to R485 per lens or one pair of clear flat top Multifocal lenses limited to R850 per lens OR CONTACT LENSES – Contact Lenses to the value of R1 005. |
| OVER THE COUNTER MEDICATION | 50% SEP plus a dispensing fee, subject to MMAP, limited to R2 220 per beneficiary. Subject to limit (a) |
| 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 | 100% of CBT, Subject to limit (b) dental implants excluded |
| DENTAL IMPLANTS | No Benefit |
| 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 | No Benefit |
| RATES | Total Monthly Contribution, Monthly income: R0 – R20 000, Principal R1 850, Adult R1 850, 1st Child (rest are free) R1 925, Monthly income: R20 001 – R24 710, Principal R2 465, Adult R2 070, 1st Child (rest are free) R1 090, Monthly income: R24 711 – R33 120, Principal R2 940, Adult R2 345, 1st Child (rest are free) R1 345, Monthly income: R33 121 – R49 690, Principal R3 585, Adult R2 785, Child R1 790, Monthly income: R49 691+, Principal R4 855, Adult R3 925, Child R2 395 |
| BenefitOptionWizard: Hospitals | Hospitals, Network Hospital |
| BenefitOptionWizard: Doctors' Rates | Doctors' Rates (In Hospital), 100% CBT |
| BenefitOptionWizard: Chronic Conditions | Chronic Conditions, Standard List of Conditions |
| BenefitOptionWizard: Radiology & Pathology | Radiology & Pathology, Limited In/Out of Hospital |
| BenefitOptionWizard: Day to Day | Day to Day, Limited |
| BenefitOptionWizard: Medical Savings | Medical Savings Account, Without MSA |
| BenefitOptionWizard: Post-hospital Cover | Post-hospital Cover, Without Cover |
