CAMAF Benefit Brochure 2014
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BASIC AND ADVANCED RADIOLOGY OUT OF HOSPITAL MUST BE PERFORMED BY A REGISTERED RADIOLOGIST, ON REFERRAL FROM MEDICAL PRACTITIONER ONLY. ADVANCED SCANS SUBJECT TO PRE-AUTHORISATION 100% CBT 100% CBT 100% CBT Subject to Medical Savings Account 100% CBT limited to R 3 030 per beneficiary Basic Radiology - as per protocols (including Mammograms for females of 40+) Referrals by DSP or specialist, 100% CBT limited to R 3 030 per beneficiary PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate Subject to Medical Savings Account 100% CBT limited to R 4 440 per beneficiary Basic Pathology - as per protocols referred by DSP or specialist, 100% CBT, limited to R 4 810 per beneficiary POST-HOSPITALISATION CONSULTATIONS AND TREATMENT UP TO 90 DAYS 300% CBT for attending practitioners 100% CBT for auxiliary services 300% CBT for attending practitioners 100% CBT for auxiliary services 300% CBT for attending practitioners 100% CBT for auxiliary services Subject to Medical Savings Account No Benefit No Benefit 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 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT Subject to Medical Savings Account No Benefit except for Depression No Benefit EXTERNAL APPLIANCES IN AND OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE HEARING AIDS - 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 - 4 YEAR CYCLE 100% of cost subject to the overall limit of R 58 400 per beneficiary and subject to the following sub-limits: Hearing Aids: R 58 400 Wheelchairs for Quadriplegics: R 58 400 Standard Wheelchairs: R 35 000 Insulin Pumps: R 35 000 Other external appliances: R 11 700 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000 100% of cost subject to the overall limit of R 46 700 per beneficiary and subject to the following sub-limits: Hearing Aids: R 46 700 Wheelchairs for Quadriplegics: R 46 700 Standard Wheelchairs: R 29 800 Insulin Pumps: R 30 400 Other external appliances: R 9 950 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000 100% of cost subject to the overall limit of R 26 900 per beneficiary and subject to the following sub-limits: Hearing Aids: R 23 300 Wheelchairs for Quadriplegics: R 23 300 Standard Wheelchairs: R 16 400 Insulin Pumps: R 26 900 Other external appliances: R 5 850 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000 Subject to Medical Savings Account 100% of cost in hospital and 80% of cost out of hospital with an overall limit of R 11 800 per beneficiary and subject to the following sub-limits: • Baby Apnoea monitors: R 1 600 • Breast pumps: R 2 700 100% of cost limited of R 4 500 per beneficiary and subject to DSP referral and subject to the following sub-limits: • Baby Apnoea monitors: R 1 600 • Breast pumps: R 2 700 NETCARE 911 EMERGENCY SERVICES Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 DAY TO DAY BENEFITS BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT Annual Overall Limits Adult R 22 100 Child R 14 200 Annual Overall Limits Adult R 8 650 Child R 6 050 No Benefit Limited to funds available in the beneficiary’s Medical Savings Account Annual overall limit: Beneficiary specific limits: (a) Medicines R 2 160 (b) Advanced Dentistry R 4 670 (c) Other R 2 160 GP’S, SPECIALISTS AND DENTISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY 80% CBT 80% CBT No Benefit Subject to Medical Savings Account 80% CBT Subject to limit (c) General practitioner consultations: 10 per beneficiary through a DSP Specialist consultations: 100% CBT limited to R 6 870 per family, only on referral from your network GP Basic dentistry: 100% Scheme Tariff at network provider only ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS 80% SEP plus a dispensing fee 80% SEP plus a dispensing fee No Benefit Subject to Medical Savings Account 80% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a) 100% SEP plus a dispensing fee for basic formulary and 80% SEP plus dispensing fee for extended formulary, both subject to MMAP NON-DSP VISITS TO DOCTORS’ ROOMS Not applicable Not applicable Not applicable Not applicable Not applicable One non-network visit per beneficiary or two per family, 20% co-payment AND One casualty visit (facility fee, consumed meds and materials). Limited to R 1 120 CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATIONS WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT 80% CBT 80% CBT No Benefit Subject to Medical Savings Account Medication: 80% SEP plus a dispensing fee subject to limit (a) Treatment: 80% CBT subject to limit (c) HOME NURSING 80% CBT up to 21 days 80% CBT up to 21 days No Benefit Subject to Medical Savings Account 80% CBT subject to limit (c) No Benefit AUXILIARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMOEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, PODIATRY AND SPEECH THERAPY 80% CBT 80% CBT No Benefit Subject to Medical Savings Account 80% CBT subject to sub-limit R 1 180 Subject to limit (c) Occupational therapy and physiotherapy only 100% CBT limited to R 1 870 per beneficiary on referral from DSP only BENEFIT SPECIFIC LIMITS ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES 80% CBT limited to: Mo R 11 700 M1 R 17 500 M2+ R 21 000 Subject to Annual Benefits 80% CBT limited to: Mo R 8 650 M1 R 12 500 M2+ R 16 900 Subject to Annual Benefits No Benefit Subject to Medical Savings Account 50% CBT Subject to limit (b) excluding dental implants 100% of CBT at network provider only, limited to R 2 690 per beneficiary OVER THE COUNTER MEDICATION 80% SEP plus a dispensing fee, limited to R 2 920 per beneficiary 80% SEP plus a dispensing fee, limited to R 1 290 per beneficiary No Benefit Subject to Medical Savings Account 80% SEP plus a dispensing fee, subject to MMAP, limited to R 1 240 per beneficiary. Subject to limit (a) 80% SEP plus a dispensing fee, subject to MMAP, limited to R760 per beneficiary LASER K NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS 80% CBT limited to R 8 750 per eye 80% CBT limited to R 3 250 per eye No Benefit Subject to Medical Savings Account No Benefit No Benefit ANTE-NATAL FOETAL SCANS PER PREGNANCY 6 Scans at 80% CBT 4 Scans at 80% CBT No Benefit Subject to Medical Savings Account 3 scans at 80% CBT. Subject to limit(c) 3 scans at 80% CBT ANTE-NATAL CLASSES SUBJECT TO ENROLMENT ON THE MOTHER-TO-BE PROGRAMME 80% CBT limited to R 1 750 per pregnancy 80% CBT limited to R 1 290 per pregnancy No Benefit Subject to Medical Savings Account 80% CBT subject to sub-limit R 770 Subject to limit (c) No Benefit SPECTACLES AND LENSES FROM OPTOMETRIST ONLY ANNUAL BENEFIT, UNLESS OTHERWISE STATED Consultation: See Preventative Wellness Add ons R 930 Single vision R 1 170 OR Bifocal R 2 340 OR Varifocal R 3 520 AND Frames R 4 650 OR Contact lenses R 5 850 Lenses, frames etc 80% Optical Assistant Rates Consultation: See Preventative Wellness Add ons R 760 Single vision R 760 OR Bifocal R 2 060 OR Varifocal R 3 160 AND Frames R 2 110 OR Contact lenses R 2 920 Lenses, frames etc 80% Optical Assistant Rates Consultation: Part of Preventative Wellness Subject to Medical Savings Account HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION 100% of Negotiated Rate in general ward and specialised units. Private ward for confinements (subject to availability) 100% of Negotiated Rate in general ward and specialised units 100% of Negotiated Rate in general ward and specialised units 100% of Negotiated Rate in general ward and specialised units 100% of Negotiated Rate in general ward and specialised units 100% DSP tariff as per protocols ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS MEDICAL AND SURGICAL PROCEDURES INCLUDING CONFINEMENTS Up to 300% CBT 100% of Scheme Rate Up to 300% CBT 100% of Scheme Rate Up to 300% CBT 100% of Scheme Rate Up to 200% CBT 100% of Scheme Rate Up to 100% CBT 100% CBT Up to 100% CBT 100% CBT AUXILIARY HEALTHCARE IN HOSPITAL (EG. PHYSIOTHERAPY AND PSYCHOTHERAPY) 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT Physiotherapy limited to R 8 700 per family BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost RADIOLOGY IN HOSPITAL ADVANCED SCANS SUBJECT TO PRE-AUTHORISATION 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT limited to R 23 600 per beneficiary - in or out of hospital 100% CBT 100% CBT limited to R 26 000 per family - in or out of hospital PATHOLOGY IN HOSPITAL 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% CBT 100% CBT INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost limited to R 26 000 per family HOME NURSING UP TO 21 DAYS, SUBJECT TO PRE- AUTHORISATION 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT (in lieu of hospitalisation only) STEP DOWN APPROVED FACILITIES ONLY, UP TO 90 DAYS SUBJECT TO PRE-AUTHORISATION 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% DSP Tariff MEDICATION IN HOSPITAL 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee TTO MEDICATION UP TO ONE WEEK’S SUPPLY 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee INFERTILITY TREATMENT Treatment limited to R 58 400 per family Treatment limited to R 40 900 per family No benefit No benefit No benefit 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 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 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 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 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 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 AND PROTOCOLS REFER TO CHRONIC DISEASE LIST 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to MMAP and based on a formulary and DSP (Consultations and procedures - at cost) PMB DTP TREATMENT OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF CONDITION AND PRE-AUTHORISATION Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) CAMAF LIFESTYLE PROGRAMME PER ADULT BENEFICIARY ONE GP CONSULTATION ONLY ICD 10 CODE SPECIFIC TO GENERAL CHECK UP ONLY 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECK UP ONLY. GYNAECOLOGISTS, UROLOGISTS, OR SPECIALIST PHYSICIANS FOR BENEFICIARIES OVER 16 YEARS. PAEDIATRICIAN FOR BENEFICIARIES UNDER 16 YEARS. 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits PSYCHOTHERAPY SUBJECT TO REGISTRATION ON EMOTIONAL WELLNESS PROGRAMME 100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 80% CBT limited to R 7 000 per beneficiary 100% CBT for PMB DTP conditions, in or out of hospital DIETICIAN CONSULTATION One per beneficiary per annum 100% CBT One per beneficiary per annum 100% CBT No Benefit Subject to Medical Savings Account No Benefit No Benefit ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECK UP ONLY *Refer to website for relevant ICD 10 codes 100% CBT per adult beneficiary 100% CBT per adult beneficiary 100% CBT per adult beneficiary Subject to Medical Savings Account 80% CBT per adult beneficiary Refer to GP, Specialist and Dentist under Other Benefits ONE CONSULTATION AT AN OPTOMETRIST 100% Optical Assistant Rates 100% Optical Assistant Rates 100% Optical Assistant Rates Subject to Medical Savings Account Refer to spectacle and lenses benefits Refer to spectacle and lenses benefits METABOLIC SCREENING FOR NEW BORN BABIES 100% Negotiated Rate per new born baby 100% Negotiated Rate per new born baby 100% Negotiated Rate per new born baby Subject to Medical Savings Account 80% Negotiated Rate per new born baby No Benefit IMMUNISATION (COST OF IMMUNISATION ONLY) SEP plus a dispensing fee, limited to R 3 520 per beneficiary SEP plus a dispensing fee, limited to: Adults R 1 750 - Child R 2 920 SEP plus a dispensing fee, limited to R 1 170 per beneficiary SEP plus a dispensing fee, limited to R 1 170 per beneficiary. SEP plus a dispensing fee, subject to MMAP, limited to R 1 170 per beneficiary SEP plus a dispensing fee, subject to MMAP, limited to R 1 170 per beneficiary CERVICAL CANCER VACCINE (COST OF VACCINE ONLY) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) SCREENING SCANS SUCH AS BONE DENSITOMETRY AND MAMMOGRAMS AT PROVIDERS WHO ARE NOT RADIOLOGISTS 100% of CBT limited to R 1 500 per beneficiary 100% of CBT limited to R 1 200 per beneficiary No Benefit Subject to Medical Savings Account No Benefit No Benefit
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Transcript of CAMAF Benefit Brochure 2014
BASIC AND ADVANCED RADIOLOGYOUT OF HOSPITAL
MUST BE PERFORMED BY A REGISTERED RADIOLOGIST, ON REFERRAL FROM MEDICAL
PRACTITIONER ONLY. ADVANCED SCANS SUBJECT TO PRE-AUTHORISATION
100% CBT 100% CBT 100% CBT Subject to Medical Savings Account 100% CBT limited to R 3 030 per beneficiary
Basic Radiology - as per protocols(including Mammograms for females of 40+)Referrals by DSP or specialist,100% CBT limited to R 3 030 per beneficiary
PATHOLOGYOUT OF HOSPITAL
PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER
100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate Subject to Medical Savings Account 100% CBT limited to R 4 440 per beneficiary Basic Pathology - as per protocols referred by DSP or specialist, 100% CBT, limited to R 4 810 per beneficiary
POST-HOSPITALISATION CONSULTATIONS AND TREATMENT
UP TO 90 DAYS
300% CBT for attending practitioners100% CBT for auxiliary services
300% CBT for attending practitioners100% CBT for auxiliary services
300% CBT for attending practitioners100% CBT for auxiliary services Subject to Medical Savings Account No Benefit No Benefit
MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS
(SUBJECT TO PRE-AUTHORISATION) REFER TO ADDITIONAL CHRONIC
CONDITIONS LIST
100% SEP plus a dispensing fee, subject toRP and DSP Consultations 100% CBT
100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT
100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT
Subject to Medical Savings Account No Benefit except for Depression No Benefit
EXTERNAL APPLIANCES IN AND OUT OF HOSPITAL
PURCHASE, HIRE AND MAINTENANCEHEARING AIDS - 1 CLAIM PER 3 YEAR
CYCLE FOR OVER 16 YEARS OF AGE YOUNGER THAN 16 YEARS OF AGE
- 18 MONTH CYCLEWHEELCHAIRS - 3 YEAR CYCLE
INSULIN PUMPS, SUBJECT TOPRE-AUTHORISATION - 4 YEAR CYCLE
100% of cost subject to the overall limit of R 58 400 per beneficiary and subject to the following sub-limits:
Hearing Aids: R 58 400Wheelchairs forQuadriplegics: R 58 400Standard Wheelchairs: R 35 000Insulin Pumps: R 35 000Other external appliances: R 11 700 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000
100% of cost subject to the overall limit of R 46 700 per beneficiary and subject to the following sub-limits:
Hearing Aids: R 46 700Wheelchairs forQuadriplegics: R 46 700Standard Wheelchairs: R 29 800Insulin Pumps: R 30 400Other external appliances: R 9 950 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000
100% of cost subject to the overall limit of R 26 900 per beneficiary and subject to the following sub-limits:
Hearing Aids: R 23 300Wheelchairs forQuadriplegics: R 23 300Standard Wheelchairs: R 16 400Insulin Pumps: R 26 900Other external appliances: R 5 850 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000
Subject to Medical Savings Account
100% of cost in hospital and 80% of cost out of hospital with an overall limit of R 11 800 per beneficiary and subject to the following sub-limits:
• Baby Apnoea monitors: R 1 600 • Breast pumps: R 2 700
100% of cost limited of R 4 500 per beneficiary and subject to DSP referral and subject to the followingsub-limits:
• Baby Apnoea monitors: R 1 600 • Breast pumps: R 2 700
NETCARE 911EMERGENCY SERVICES
UnlimitedSubject to Netcare 911 authorisation
UnlimitedSubject to Netcare 911 authorisation
UnlimitedSubject to Netcare 911 authorisation
UnlimitedSubject to Netcare 911 authorisation
UnlimitedSubject to Netcare 911 authorisation
UnlimitedSubject to Netcare 911
DAY TO DAY BENEFITSBENEFITS BELOW ARE SUBJECT TO THE
OVERALL ANNUAL LIMIT
Annual Overall LimitsAdult R 22 100Child R 14 200
Annual Overall LimitsAdult R 8 650Child R 6 050
No Benefit Limited to funds available in the beneficiary’s Medical Savings Account
Annual overall limit: Beneficiary specific limits:(a) Medicines R 2 160(b) Advanced Dentistry R 4 670(c) Other R 2 160
GP’S, SPECIALISTS AND DENTISTSCONSULTATIONS, PROCEDURES AND
RADIOLOGY PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY
80% CBT 80% CBT No Benefit Subject to Medical Savings Account 80% CBTSubject to limit (c)
General practitioner consultations: 10 per beneficiary through a DSP Specialist consultations: 100% CBT limited to R 6 870 per family, only on referral from your network GP Basic dentistry: 100% Scheme Tariff at network provider only
ACUTE MEDICATIONINCLUDING INJECTIONS AND MATERIALS 80% SEP plus a dispensing fee 80% SEP plus a dispensing fee No Benefit Subject to Medical Savings Account 80% SEP plus a dispensing fee, subject to MMAP.
Subject to limit (a)
100% SEP plus a dispensing fee for basic formulary and 80% SEP plus dispensing fee for extended formulary, both subject to MMAP
NON-DSP VISITSTO DOCTORS’ ROOMS Not applicable Not applicable Not applicable Not applicable Not applicable One non-network visit per beneficiary or two per family,
20% co-paymentANDOne casualty visit (facility fee, consumed meds and materials).Limited to R 1 120
CASUALTY AND OUT PATIENTTREATMENT AT A HOSPITAL
ALL MEDICATIONS WILL BE PAID OUT OFACUTE MEDICATION BENEFIT
80% CBT 80% CBT No Benefit Subject to Medical Savings AccountMedication: 80% SEP plus a dispensing feesubject to limit (a)Treatment: 80% CBT subject to limit (c)
HOME NURSING 80% CBT up to 21 days 80% CBT up to 21 days No Benefit Subject to Medical Savings Account 80% CBT subject to limit (c) No Benefit
AUXILIARY HEALTHAUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMOEOPATHS, OCCUPATIONAL THERAPY,
PHYSIOTHERAPISTS, PODIATRY AND SPEECH THERAPY
80% CBT 80% CBT No Benefit Subject to Medical Savings Account 80% CBT subject to sub-limit R 1 180Subject to limit (c)
Occupational therapy and physiotherapy only 100% CBT limited to R 1 870 per beneficiary on referral from DSP only
BENEFIT SPECIFIC LIMITS
ADVANCED DENTISTRYCROWNS, BRIDGES,
ORTHODONTICS, DENTURES
80% CBT limited to:Mo R 11 700M1 R 17 500M2+ R 21 000Subject to Annual Benefits
80% CBT limited to:Mo R 8 650M1 R 12 500M2+ R 16 900Subject to Annual Benefits
No Benefit Subject to Medical Savings Account 50% CBTSubject to limit (b) excluding dental implants
100% of CBT at network provider only, limited to R 2 690 per beneficiary
OVER THE COUNTER MEDICATION 80% SEP plus a dispensing fee, limited to R 2 920 per beneficiary
80% SEP plus a dispensing fee, limited to R 1 290 per beneficiary No Benefit Subject to Medical Savings Account 80% SEP plus a dispensing fee, subject to MMAP, limited
to R 1 240 per beneficiary. Subject to limit (a)80% SEP plus a dispensing fee, subject to MMAP, limited to R760 per beneficiary
LASER KNO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS
12 MONTHS
80% CBT limited to R 8 750 per eye 80% CBT limited to R 3 250 per eye No Benefit Subject to Medical Savings Account No Benefit No Benefit
ANTE-NATAL FOETAL SCANSPER PREGNANCY 6 Scans at 80% CBT 4 Scans at 80% CBT No Benefit Subject to Medical Savings Account 3 scans at 80% CBT. Subject to limit(c) 3 scans at 80% CBT
ANTE-NATAL CLASSESSUBJECT TO ENROLMENT ON THE
MOTHER-TO-BE PROGRAMME80% CBT limited to R 1 750 per pregnancy 80% CBT limited to R 1 290 per pregnancy No Benefit Subject to Medical Savings Account 80% CBT subject to sub-limit R 770
Subject to limit (c) No Benefit
SPECTACLES AND LENSESFROM OPTOMETRIST ONLY
ANNUAL BENEFIT, UNLESS OTHERWISE STATED
Consultation: See Preventative WellnessAdd ons R 930Single vision R 1 170ORBifocal R 2 340ORVarifocal R 3 520ANDFrames R 4 650ORContact lenses R 5 850Lenses, frames etc 80% Optical Assistant Rates
Consultation: See Preventative WellnessAdd ons R 760Single vision R 760 ORBifocal R 2 060 ORVarifocal R 3 160 ANDFrames R 2 110 ORContact lenses R 2 920 Lenses, frames etc 80% Optical Assistant Rates
Consultation:Part of Preventative Wellness Subject to Medical Savings Account
HOSPITAL ACCOMMODATIONINCLUDING CONFINEMENTS,
SUBJECT TO PRE-AUTHORISATION
100% of Negotiated Rate in general ward and specialised units. Private ward for confinements(subject to availability)
100% of Negotiated Rate in general ward and specialised units
100% of Negotiated Rate in general ward and specialised units
100% of Negotiated Rate in general ward and specialised units
100% of Negotiated Rate in general ward and specialised units 100% DSP tariff as per protocols
ATTENDING DOCTORS AND SPECIALISTSCONSULTATIONS
MEDICAL AND SURGICAL PROCEDURESINCLUDING CONFINEMENTS
Up to 300% CBT 100% of Scheme Rate
Up to 300% CBT 100% of Scheme Rate
Up to 300% CBT 100% of Scheme Rate
Up to 200% CBT 100% of Scheme Rate
Up to 100% CBT 100% CBT
Up to 100% CBT 100% CBT
AUXILIARY HEALTHCARE IN HOSPITAL(EG. PHYSIOTHERAPY
AND PSYCHOTHERAPY)100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT
Physiotherapy limited to R 8 700 per family
BLOOD TRANSFUSIONS(IN AND OUT OF HOSPITAL) 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost
RADIOLOGY IN HOSPITALADVANCED SCANS
SUBJECT TO PRE-AUTHORISATION
100% CBT100% CBT
100% CBT100% CBT
100% CBT100% CBT
100% CBT100% CBT
100% CBT100% CBT limited to R 23 600 per beneficiary - in or out of hospital
100% CBT100% CBT limited to R 26 000 per family - in or out of hospital
PATHOLOGYIN HOSPITAL 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% CBT 100% CBT
INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost limited to R 26 000 per family
HOME NURSING UP TO 21 DAYS, SUBJECT TO PRE-
AUTHORISATION100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT (in lieu of hospitalisation only)
STEP DOWN APPROVED FACILITIESONLY, UP TO 90 DAYS
SUBJECT TO PRE-AUTHORISATION100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% DSP Tariff
MEDICATIONIN HOSPITAL 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee
TTO MEDICATIONUP TO ONE WEEK’S SUPPLY
100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee
INFERTILITY TREATMENT Treatment limited to R 58 400 per family Treatment limited to R 40 900 per family No benefit No benefit No benefit No benefit
SUBSTANCE ABUSEPMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days
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
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
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
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
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 MEDICATIONAND TREATMENT - SUBJECT TO PRE-
AUTHORISATION AND PROTOCOLSREFER TO CHRONIC DISEASE LIST
100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
100% SEP plus a dispensing fee, subject to MMAP and based on a formulary and DSP(Consultations and procedures - at cost)
PMB DTP TREATMENTOUT OF HOSPITAL TREATMENT SUBJECT
TO REGISTRATION OF CONDITION ANDPRE-AUTHORISATION
Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost)
CAMAF LIFESTYLE PROGRAMMEPER ADULT BENEFICIARY
100% of Negotiated Rate in general ward and specialised units
100% of Negotiated Rate in general ward and specialised units
100% of Negotiated Rate in general ward and specialised units
100% of Negotiated Rate in general ward and specialised units 100% DSP tariff as per protocols
ONE GP CONSULTATION ONLYICD 10 CODE SPECIFIC TO GENERAL
CHECK UP ONLY100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits
ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TOGENERAL CHECK UP ONLY.
GYNAECOLOGISTS, UROLOGISTS, OR SPECIALIST PHYSICIANS FOR BENEFICIARIES OVER 16 YEARS.
PAEDIATRICIAN FOR BENEFICIARIES UNDER 16 YEARS.
100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits
PSYCHOTHERAPYSUBJECT TO REGISTRATION ON
EMOTIONAL WELLNESS PROGRAMME100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 80% CBT limited to R 7 000 per beneficiary 100% CBT for PMB DTP conditions, in or out of hospital
DIETICIAN CONSULTATION One per beneficiary per annum100% CBT
One per beneficiary per annum100% CBT No Benefit Subject to Medical Savings Account No Benefit No Benefit
ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits
ECG(PERFORMED BY GP OR SPECIALIST
PHYSICIAN)*ICD 10 CODE SPECIFIC TO GENERAL
CHECK UP ONLY*Refer to website for relevant ICD 10 codes
100% CBT per adult beneficiary 100% CBT per adult beneficiary 100% CBT per adult beneficiary Subject to Medical Savings Account 80% CBT per adult beneficiary Refer to GP, Specialist and Dentist under Other Benefits
ONE CONSULTATION AT AN OPTOMETRIST 100% Optical Assistant Rates 100% Optical Assistant Rates 100% Optical Assistant Rates Subject to Medical Savings Account Refer to spectacle and lenses benefits Refer to spectacle and lenses benefits
METABOLIC SCREENING FORNEW BORN BABIES 100% Negotiated Rate per new born baby 100% Negotiated Rate per new born baby 100% Negotiated Rate per new born baby Subject to Medical Savings Account 80% Negotiated Rate per new born baby No Benefit
IMMUNISATION(COST OF IMMUNISATION ONLY)
SEP plus a dispensing fee, limited to R 3 520 per beneficiary
SEP plus a dispensing fee, limited to: Adults R 1 750 - Child R 2 920
SEP plus a dispensing fee, limited to R 1 170 per beneficiary
SEP plus a dispensing fee, limited to R 1 170 per beneficiary.
SEP plus a dispensing fee, subject to MMAP, limited to R 1 170 per beneficiary
SEP plus a dispensing fee, subject to MMAP, limited to R 1 170 per beneficiary
CERVICAL CANCER VACCINE(COST OF VACCINE ONLY)
Females between 9 and 16 years of age(SEP plus dispensing fee)
Females between 9 and 16 years of age(SEP plus dispensing fee)
Females between 9 and 16 years of age(SEP plus dispensing fee)
Females between 9 and 16 years of age(SEP plus dispensing fee)
Females between 9 and 16 years of age(SEP plus dispensing fee)
Females between 9 and 16 years of age(SEP plus dispensing fee)
SCREENING SCANSSUCH AS BONE DENSITOMETRY AND MAMMOGRAMS AT PROVIDERS WHO
ARE NOT RADIOLOGISTS
100% of CBT limited to R 1 500 per beneficiary 100% of CBT limited to R 1 200 per beneficiary No Benefit Subject to Medical Savings Account No Benefit No Benefit
ADULT Refers to the member and dependants who are 22 or older at any time in the year of cover.
CBTCAMAF Base Tariff - the maximum rate paid by the Scheme to providers of healthcare services, based on 2009 RPL (Medical Aid) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options.
CDLChronic Disease List - the list of PMB’s includes 27 common chronic conditions called CDL’s. Schemes must provide cover for the diagnosis, treatment and care of these conditions. Members must register their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSP’s).
CML/ FORMULARYCondition Medicine List - once a patient’s chronic condition has been registered, a patient will have access to the CML. This is a list of drugs, appropriate for the condition, that do not require authorisation. This is maintained by the Scheme and differs per Option. Reference pricing may still apply.
CHILD Refers to a dependant who is younger than an adult, as defined above.
DISPENSING FEES Fee negotiated by the Scheme with Network pharmacies and added to SEP.
DSPThe network of service providers contracted to provide healthcare services to members, eg. Diabetes programme (CDE), HIV programme (LifeSense) PPN for optical benefits on First Choice and Network Choice, Pharmacy networks for all chronic medications and Netcare hospital group for Network Choice hospital admissions.
DTP
The Regulations to the Medical Schemes Act in Annexure A provide a list of conditions identified as Prescribed Minimum Benefits. The List is in the form of Diagnosis Treatment Pairs (DTP’s). A DTP links a specific diagnosis to a treatment/procedure and therefore broadly indicates how each of the 270 PMB conditions should be treated. These treatment pairs cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions.
ICD 10 CODE
Stands for International Classification of Diseases and Related Health Problems (10th revision). It is a coding system developed by the World Health Organisation (WHO) that translates the written description of medical and health information into standard codes, e.g. Jo3.9 is an ICD-10 code for acute tonsillitis (unspecified) and G40.9 denotes epilepsy (unspecified). These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be paid from the correct benefit.
MEDICAL SAVINGS ACCOUNT
A savings account that accrues monthly but the annualised amount of savings is available immediately and can be used for: • top up on cost of service charged by a doctor • extension when an overall benefit has been exceeded • exclusion from benefits • payment of day to day claims on Essential Plus option
METABOLIC SCREENING Newborn screening whereby rare disorders are detected by a blood test done 48 - 72 hours after birth.
MMAPMaximum Medical Aid Price - is a reference price model and determines the maximum medical scheme price that medical schemes will reimburse for an interchangeable multi-source pharmaceutical product (generic) on the relevant option. MMAP applies to all options for chronic medication.
NEGOTIATED RATE This is the rate, negotiated by the scheme with the service provider/group of service providers, eg. hospitals and pathologists.
PMB
Prescribed Minimum Benefits - as set out in the Medical Schemes Act, 1998. Medical schemes have to cover the costs related to the diagnosis, treatment and care of: • Any emergency medical condition • A limited set of 270 medical conditions (Defined in DTP’s) • 27 chronic conditions defined in the CDL • These costs may not be paid from the member’s savings benefit and cost saving measures can be used by way of utilising DSP’s, Reference Pricing and Formularies.
PRE-AUTHORISATION A member must obtain prior approval for an intended admission to hospital. Failure to pre-authorise could result in wholly or partly disallowing the claim or imposing a penalty of 20% of related accounts up to a maximum of R 2 500. Emergency treatment is not subject to Pre-authorisation but members should notify the Scheme as soon as possible after the event.
PROTOCOLMeans a set of guidelines in relation to diagnostic testing and management of specific conditions and includes, but is not limited to, clinical practice guidelines, standard treatment guidelines and disease management guidelines.
RISK CONTRIBUTIONSThose funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account.
RPReference Pricing is the maximum price for which the Scheme will be liable for specific medicine or classes of medicine, listed on the Scheme’s Condition Medicine List (CML). The reference price varies per option and where a drug is above the reference price it is indicated that a co-payment will apply. This includes MMAP.
SALARY Total cost to company prior to deductions.
SCHEME RATEThe maximum rate paid by the scheme to providers of healthcare services, based on SAMA (Private) rates, increased annually by CPI. Tariff differs per type of service provider and % paid on different options.
SEPSingle Exit Price - nationally applied pricing for medication as determined by the Department of Health and the pharmaceutical manufacturers.
TTO “To Take Out” - medication supplied by the hospital for use after the date of discharge from hospital - limited to a 7 day supply.
Monthly Risk Contribution
Adult R 3 349Child R 1 894
Monthly MSA Contribution
Adult R 434Child R 207
Total Monthly Contribution
Adult R 3 783Child R 2 101
Monthly Risk Contribution
Adult R 2 218Child R 1 321
Monthly MSA Contribution
Adult R 283Child R 184
Total Monthly Contribution
Adult R 2 501Child R 1 505
Total Monthly Contribution
Adult R 1 433Child R 777
Monthly Risk Contribution
Principal R 1 108Adult R 881Child R 535
NEW Monthly MSA Contribution
Principal R 369Adult R 294Child R 178
Total Monthly Contribution
Principal R 1 477Adult R 1 175Child R 713
Income Category
R 0 - R 3 470Adult R 321Child R 179
R 3 471 - R 6 770Adult R 632Child R 376
R 6 771 - R 13 080Adult R 1 002Child R 583
R 13 081 - R 18 530Adult R 1 498Child R 860
R 18 531+Adult R 1 866Child R 1 201
Income Category
R 0 - R 16 890Principal R 1 008Adult R 8511st Child R 454(rest are free)
R 16 891 - 27 800Principal R 1 339Adult R 1 046Child R 697
R 27 801 +Principal R 1 783Adult R 1 452Child R 914
RESPIRATORY PROGRAMME
Telephone 0861 700 600
Fax 011 707 8622
E-mail [email protected]
STRESSLINE
Telephone 0861 700 600
Fax 011 707 8747
E-mail [email protected]
REALITY (LOYALTY PROGRAMME)
General Enquires 0860 REALITY (732 5489)
Fax 021 700 8750
E-mail [email protected]
Website www.reality.co.za
FOR FIRST CHOICE AND NETWORK CHOICE MEMBERS ONLY
PPN CALL CENTRE
Telephone 0860 103 529
Post Claims To PO Box 12450, Centrahil, 6006
Website www.ppn.co.za
CAMAF
Client Relations* 0860 100 545
E-mail [email protected]
Fax 0861 113 676
Reception 0861 700 600
Hospital Pre-authorisations 0860 100 544
Hospital Pre-authorisations Fax 011 706 9946
Hospital Pre-authorisations E-mail [email protected]
Hospital Pre-authorisations Online www.camaf.co.za
Website www.camaf.co.za
Membership Fax 011 707 8735
Post Claims to: PO Box 2964, Randburg, 2125
CAMAF LIFESTYLE PROGRAMME
Telephone 0860 200 911
E-mail [email protected]
CANCER WELLNESS PROGRAMME
Telephone 0860 100 544
CARDIAC SUPPORT LINE
Telephone 0860 100 544
CENTRE FOR DIABETES AND ENDOCRINOLOGY (CDE) DISEASE MANAGEMENT PROGRAMME
Emergency Contact Number 082 456 7844
General Enquires 011 712 6000
Website www.cdecentr.co.za
CHRONIC CONDITION AUTHORISATION
Telephone for:
Doctors and Pharamacists only / SwiftAuth 0800 200 300
Members 0861 700 600 Option3
Fax 011 707 8622
E-mail [email protected]
EMOTIONAL WELLNESS PROGRAMME
Telephone 0860 100 544
Fax 011 707 8747
E-mail [email protected]
HYPERTENSION AND CHOLESTEROL PROGRAMME
Telephone 0861 700 600
LIFESENSE (HIV DISEASE MANAGEMENT PROGRAMME)
24 Hour Call Centre 0860 506 080
E-mail [email protected]
MOTHER-TO-BE PROGRAMME
Telephone 0860 100 544
NETCARE 911
Emergency Number 082 911
Telephone 011 254 1911
Fax 011 254 1950
Namibia 09264 61 230 612
PMB DTP AUTHORISATION
Fax 011 707 8866
E-mail [email protected]
Addison’s Disease
Asthma*
Bipolar Mood Disorder*
Bronchiectasis*
Cardiac Failure
Cardiomyopathy
Chronic Obstructive Pulmonary Disorder (COPD)*
Chronic Renal Disease
Coronary Artery Disease
Crohn’s Disease
Diabetes Insipidus
Diabetes Mellitus Type 1*
Diabetes Mellitus Type 2*
Dysrhythmia
Epilepsy
Glaucoma
Haemophilia A & B
HIV/AIDS*
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinson’s Disease
Rheumatoid Arthritis
Schizophrenia*
Systemic Lupus Erythematosus
Ulcerative Colitis
Oncology* (PMB DTP) consult website for further details
*Subject to registration on relevant Wellness Programme
ADHD (Alliance only)
Agranulocytosis
Allergic Rhinitis
Alzheimer’s Disease
Anaemias: Aplastic, Haemolytic, Sickle Cell
Ankylosing Spondylitis
Benign Prostatic Hypertrophy
Chronic Granulomatous Disease
Coagulation Disorders
Congenital Heart Malformations
Cystic Fibrosis
Deep Vein Thrombosis
Depression* (includes First Choice and Essential Plus)
Eczema
Endometriosis
Gastro-Oesophageal Reflux Disease (GORD)
Gaucher’s Disease
Gout Prophylaxis
Hormone Replacement Therapy
Hyperparathyroidism
Hyperthyroidism
Meniére’s Disease
Migraine Prophylaxis
Muscular Dystrophy
Myasthenia Gravis
Narcolepsy
Organ Transplant
Osteoarthritis
Osteoporosis
Plegia: Hemi, Para & Quad
Polycystic Ovarian Syndrome
Psoriasis
Restrictive Lung Disease
Thalassaemia
Transient Ischaemic Attack / Stroke
Tuberculosis
Valvular Heart Disease*Subject to registration on relevant Wellness Programme
