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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 R47 586 per family (combined limit for in and out hospital) |
| PATHOLOGY IN HOSPITAL | 100% Negotiated Rate |
| INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION | 100% of cost limited to R47 586 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 (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 health risk assessment at Clicks, Dischem or Pick n Pay pharmacy and 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 088 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 335 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) |
| 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 838, Breast pumps: R4 880 |
| 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 308 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 565 per beneficiary, Advanced scans: 100% CBT limited to R47 586 per family (on referral by nominated network GP or specialist) |
| 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 R8 880 per beneficiary |
| 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) | 100% NAPPI price or 100% of cost, limited to R8 498 per beneficiary and subject to nominated network GP 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. | 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., 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 R 4 118, (b) Advanced Dentistry R 8 630, (c) Other R 4 118, (d) Specialists R12 670 |
| 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 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 759 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) |
| CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL | Both the non-nominated GP visit and casualty treatment is limit to R1 759 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 AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, BIOKINETICISTS, PODIATRY AND SPEECH THERAPY | 100% CBT limited to R3 465 per beneficiary on referral from a nominated network GP 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 R2 115 per beneficiary, Subject to limit (a) |
| SPECTACLES & LENSES FROM OPTOMETRIST ONLY; ANNUAL BENEFIT, UNLESS OTHERWISE STATED; WHERE PPN IS INDICATED AS THE DSP, PPN RATES & TARIFFS WILL APPLY. FOR ALL OTHER OPTIONS, OPTICAL ASSISTANT RATES | 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 R935 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 R970., 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 R380 AND, EITHER SPECTACLES – A frame benefit of R935 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 R215 per lens, or one pair of clear flat top bifocal spectacle lenses limited to R460 per lens or one pair of clear flat top Multifocal lenses limited to R810 per lens, OR CONTACT LENSES – Contact Lenses to the value of R970 |
| RATES | Total Monthly Contribution, R0 – R23 530, Principal R2 275, Adult R1 907, 1st Child (rest are free) R1 005, R23 531 – R31 540, Principal R2 710, Adult R2 160, 1st Child (rest are free) R1 238, R31 541 – R47 320, Principal R3 290, Adult R2 555, Child R1 640, R47 321+, Principal R4 435, Adult R3 585, Child R2 185 |
