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ALLIANCE DOUBLE PLUS VITAL ESSENTIAL PLUS FIRST CHOICE NETWORK CHOICE

All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
IN HOSPITAL AND PRESCRIBED MINIMUM BENEFITS
HOSPITAL ACCOMMODATION 100% of Negotiated Rate in general ward
100% of Negotiated Rate in general 100% of Negotiated Rate in general 100% of Negotiated Rate in general 100% of Negotiated Rate in general 100% DSP tariff as per protocols.
INCLUDING CONFINEMENTS, SUBJECT TO and specialised units. Private ward for
ward and specialised units ward and specialised units ward and specialised units ward and specialised units The DSP hospital group is Netcare.
PRE-AUTHORISATION confinements (subject to availability)
ATTENDING DOCTORS AND SPECIALISTS
Up to 300% CBT Up to 300% CBT Up to 300% CBT Up to 200% CBT Up to 100% CBT Up to 100% CBT
CONSULTATIONS MEDICAL AND SURGICAL
100% of Scheme Rate 100% of Scheme Rate 100% of Scheme Rate 100% of Scheme Rate 100% CBT 100% CBT
PROCEDURES INCLUDING CONFINEMENTS
AUXILIARY HEALTHCARE IN HOSPITAL 100% CBT
(EG. PHYSIOTHERAPY AND 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT Physiotherapy limited to R9 400 per
PSYCHOTHERAPY) family
BLOOD TRANSFUSIONS
100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost
(IN AND OUT OF HOSPITAL)
RADIOLOGY IN HOSPITAL 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT
ADVANCED SCANS 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT limited to R25 490 per 100% CBT limited to R28 080 per family
SUBJECT TO PRE-AUTHORISATION beneficiary - in or out of hospital - in or out of hospital
PATHOLOGY
100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% CBT 100% CBT
IN HOSPITAL
INTERNAL PROSTHESIS 100% of cost limited to R28 080 per
100% of cost 100% of cost 100% of cost 100% of cost 100% of cost
SUBJECT TO PRE-AUTHORISATION family
HOME NURSING
100% CBT (in lieu of hospitalisation
UP TO 21 DAYS, SUBJECT TO PRE- 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT
only)
AUTHORISATION
STEP DOWN APPROVED FACILITIES (ONLY,
UP TO 90 DAYS) 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% DSP Tariff
SUBJECT TO PRE-AUTHORISATION
MEDICATION
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
IN HOSPITAL
TTO MEDICATION 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
UP TO ONE WEEKS SUPPLY
INFERTILITY TREATMENT Treatment limited to R63 070 per family Treatment limited to R44 170 per family No benefit No benefit No benefit No benefit
PMB applied to hospital based treatment PMB applied to hospital based treatment PMB applied to hospital based treatment PMB applied to hospital based treatment PMB applied to hospital based treatment PMB applied to hospital based treatment
and limited to one rehabilitation and limited to one rehabilitation and limited to one rehabilitation and limited to one rehabilitation and limited to one rehabilitation and limited to one rehabilitation
SUBSTANCE ABUSE treatment per beneficiary per year, treatment per beneficiary per year, treatment per beneficiary per year, treatment per beneficiary per year, treatment per beneficiary per year, treatment per beneficiary per year,
subject to pre-authorisation and limited subject to pre-authorisation and limited subject to pre-authorisation and limited subject to pre-authorisation and limited subject to pre-authorisation and limited subject to pre-authorisation and limited
to 21 days to 21 days to 21 days to 21 days to 21 days to 21 days
CHRONIC PMB CDL MEDICATIONAND 100% SEP plus a dispensing fee, subject
100% SEP plus a dispensing fee, subject 100% SEP plus a dispensing fee, subject 100% SEP plus a dispensing fee, subject 100% SEP plus a dispensing fee, subject 100% SEP plus a dispensing fee, subject
TREATMENT - SUBJECT TO PRE- to MMAP and based on a formulary
to RP and DSP. Consultations and to RP and DSP. Consultations and to RP and DSP. Consultations and to RP and DSP. Consultations and to RP and DSP. Consultations and
AUTHORISATION AND PROTOCOLS and DSP. Consultations and procedures
procedures - at cost procedures - at cost procedures - at cost procedures - at cost procedures - at cost
REFER TO CHRONIC DISEASE LIST - at cost
PMB DTP TREATMENT Medication - 100% SEP plus a
Medication - SEP plus dispensing fee, Medication - SEP plus dispensing fee, Medication - SEP plus dispensing fee, Medication - SEP plus dispensing fee, Medication - SEP plus dispensing fee,
OUT OF HOSPITAL TREATMENT SUBJECT TO dispensing fee, subject to MMAP
subject to RP and DSP. Consultations subject to RP and DSP. Consultations subject to RP and DSP. Consultations subject to RP and DSP. Consultations subject to RP and DSP. Consultations
REGISTRATION OF CONDITION AND PRE- and based on a formulary and DSP.
and procedures - at cost and procedures - at cost and procedures - at cost and procedures - at cost and procedures - at cost
AUTHORISATION Consultations and procedures - at cost

ONCOLOGY Medication - 100% SEP plus a Medication - 100% SEP plus a


Medication - 100% SEP plus a Medication - 100% SEP plus a Medication - 100% SEP plus a Medication - 100% SEP plus a
dispensing fee, subject to MMAP
SUBJECT TO PREAUTHORISATION AND dispensing fee, subject to RP and DSP. dispensing fee, subject to RP and DSP. dispensing fee, subject to RP and DSP. dispensing fee, subject to RP and DSP. dispensing fee, subject to RP and DSP.
and based on a formulary and DSP.
PROTOCOLS Consultations and procedures - at cost Consultations and procedures - at cost Consultations and procedures - at cost Consultations and procedures - at cost Consultations and procedures - at cost
Consultations and procedures - at cost

SPECIALISED MEDICINE AND TECHNOLOGY Medication - 100% SEP plus a Medication - 100% SEP plus a
Medication - 100% SEP plus a Medication - 100% SEP plus a Medication - 100% SEP plus a Medication - 100% SEP plus a
dispensing fee, subject to MMAP
SUBJECT TO PREAUTHORISATION AND dispensing fee, subject to RP and DSP. dispensing fee, subject to RP and DSP. dispensing fee, subject to RP and DSP. dispensing fee, subject to RP and DSP. dispensing fee, subject to RP and DSP.
and based on a formulary and DSP.
PROTOCOLS Consultations and procedures - at cost Consultations and procedures - at cost Consultations and procedures - at cost Consultations and procedures - at cost Consultations and procedures - at cost
Consultations and procedures - at cost
ALLIANCE DOUBLE PLUS VITAL ESSENTIAL PLUS FIRST CHOICE NETWORK CHOICE
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
PREVENTATIVE WELLNESS COVER
CAMAF LIFESTYLE PROGRAMME INCLUDES: An initial assessment by a nurse within Clicks or Dischem clinics or at a Biokineticist within the network A personalised exercise and eating programme Reporting and goal setting Follow-up measuring and tracking at Clicks, Pick n Pay or
PER ADULT BENEFICIARY Dischem clinics, Lifezone or Healthzones Access to the Web Life Zone Regular ongoing communication Telephonic access to a coach (Biokineticist or Dietician).
ONE GP CONSULTATION ONLY
Refer to GP, Specialist and Dentist under
*ICD 10 CODE SPECIFIC TO GENERAL 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary
Other Benefits
CHECK UP ONLY
ONE SPECIALIST CONSULTATION
*ICD 10 CODE SPECIFIC TO GENERAL CHECK
UP ONLY. GYNAECOLOGISTS, UROLOGISTS,
Refer to GP, Specialist and Dentist under
OR SPECIALIST PHYSICIANS** 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary
Other Benefits
FOR BENEFICIARIES OVER 16 YEARS.
PAEDIATRICIANS FOR BENEFICIARIES UNDER 16
YEARS
PSYCHOTHERAPY
100% CBT limited to R8 750 per 100% CBT limited to R8 750 per 100% CBT limited to R8 750 per 100% CBT limited to R8 750 per 80% CBT limited toR7 560 per 100% CBT for PMB DTP conditions, in or
SUBJECT TO REGISTRATION ON EMOTIONAL
beneficiary beneficiary beneficiary beneficiary beneficiary out of hospital
WELLNESS PROGRAMME
ONE DIETICIAN CONSULTATION 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account No Benefit No Benefit
ONE DENTISTRY CONSULTATION
Refer to GP, Specialist and Dentist under
GENERAL CHECK UP ONLY - excludes 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary
Other Benefits
consumables
ECG
(PERFORMED BY GP OR SPECIALIST
Refer to GP, Specialist and Dentist under
PHYSICIAN**) 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
Other Benefits
*ICD 10 CODE SPECIFIC TO GENERAL
CHECK UP ONLY - excludes consumables
ONE OPTOMETRIST CONSULTATION 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 100% Negotiated Rate per new born 100% Negotiated Rate per new born 100% Negotiated Rate per new born 80% Negotiated Rate per new born
Subject to Medical Savings Account No Benefit
NEW BORN BABIES baby baby baby baby
SEP plus a dispensing fee, subject to
IMMUNISATION SEP plus a dispensing fee, limited to R 3 SEP plus a dispensing fee, limited to: SEP plus a dispensing fee, limited to R 1 SEP plus a dispensing fee, limited to R 1 SEP plus a dispensing fee, subject to
MMAP, limited to
(COST OF IMMUNISATION ONLY) 800 per beneficiary Adults R 1 890 - Child R 3 150 260 per beneficiary 260 per beneficiary MMAP, limited to R 1 260 per beneficiary
R 1 260 per beneficiary
CERVICAL CANCER VACCINE Females between 9 and 16 years of age Females between 9 and 16 years of age Females between 9 and 16 years of age Females between 9 and 16 years of age Females between 9 and 16 years of age Females between 9 and 16 years of age
(COST OF VACCINE ONLY) (SEP plus dispensing fee) (SEP plus dispensing fee) (SEP plus dispensing fee) (SEP plus dispensing fee) (SEP plus dispensing fee) (SEP plus dispensing fee)
ONE HIV VCT TEST 100% cost per beneficiary 100% cost per beneficiary 100% cost per beneficiary Subject to Medical Savings Account 100% cost per beneficiary 100% cost per beneficiary
SCREENING SCANS
BONE DENSITOMETRY AND MAMMOGRAMS 100% of CBT limited to R 1 300 per 100% of CBT limited to R 1 300 per 100% of CBT limited to R 1 300 per
Subject to Medical Savings Account No Benefit No Benefit
AT PROVIDERS WHO ARE NOT beneficiary beneficiary beneficiary
RADIOLOGISTS
NEW MELANOMA SCREENING TEST 100% CBT per adult beneficiary 100% CBT per adult beneficiary 100% CBT per adult beneficiary Subject to Medical Savings Account No Benefit No Benefit
NEW 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
UMBILICAL STEM CELL HARVESTING
passed directly on to you and is not paid from your health plan benefits.
ALLIANCE DOUBLE PLUS VITAL ESSENTIAL PLUS FIRST CHOICE NETWORK CHOICE
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) NOT SUBJECT TO THE ANNUAL OVERALL BENEFIT LIMIT
BASIC AND ADVANCED RADIOLOGY
OUT OF HOSPITAL Basic Radiology - as per protocols
(including Mammograms for females
MUST BE PERFORMED BY A REGISTERED 100% CBT limited to R3 270 per
100% CBT 100% CBT 100% CBT Subject to Medical Savings Account of 40+)
RADIOLOGIST, ON REFERRAL FROM MEDICAL beneficiary
Referrals by DSP or specialist, 100% CBT
PRACTITIONER ONLY. ADVANCED SCANS limited to R3 270 per beneficiary
SUBJECT TO PRE-AUTHORISATION
PATHOLOGY
OUT OF HOSPITAL Basic Pathology - as per protocols
100% CBT limited to R4 800 per
PERFORMED BY A REGISTERED 100% Negotiated Rate or CBT 100% Negotiated Rate or CBT 100% Negotiated Rate or CBT Subject to Medical Savings Account referred by DSP or specialist, 100% CBT,
beneficiary
PATHOLOGIST AND REFERRED BY A MEDICAL limited to R5 190 per beneficiary
PRACTITIONER
POST-HOSPITALISATION
300% CBT for attending practitioners 300% CBT for attending practitioners 300% CBT for attending practitioners
CONSULTATIONS AND TREATMENT Subject to Medical Savings Account No Benefit No Benefit
100% CBT for auxiliary services 100% CBT for auxiliary services 100% CBT for auxiliary services
UP TO 90 DAYS
MEDICATION FOR ADDITIONAL CHRONIC
100% SEP plus a dispensing fee, subject 100% SEP plus a dispensing fee, subject 100% SEP plus a dispensing fee, subject
CONDITIONS
to RP and DSP to RP and DSP to RP and DSP Subject to Medical Savings Account No Benefit except for Depression No Benefit
(SUBJECT TO PRE-AUTHORISATION) REFER
Consultations 100% CBT Consultations 100% CBT Consultations 100% CBT
TO ADDITIONAL CHRONIC CONDITIONS LIST
100% of cost subject to the overall limit 100% of cost subject to the overall limit 100% of cost subject to the overall limit
EXTERNAL APPLIANCES of R 63 070 per beneficiary and subject of R 50 440 per beneficiary and subject of R 29 050 per beneficiary and subject
IN AND OUT OF HOSPITAL to the following sub-limits: to the following sub-limits: to the following sub-limits:
PURCHASE, HIRE AND MAINTENANCE 100% of cost in hospital and 80% of cost
100% of cost limited of R 4 860 per
HEARING AIDS - 1 CLAIM PER 3 YEAR out of hospital with an overall limit of
Hearing Aids: R 63 070 Hearing Aids: R 50 440 Hearing Aids: R 25 160 beneficiary and subject to DSP referral
R 12 740 per beneficiary and subject to
CYCLE FOR OVER 16 YEARS OF AGE Wheelchairs for Wheelchairs for Wheelchairs for and subject to the following sub-limits:
Subject to Medical Savings Account the followingsub-limits:
YOUNGER THAN 16 YEARS OF AGE Quadriplegics: R 63 070 Quadriplegics: R 50 440 Quadriplegics: R 25 160
- 18 MONTH CYCLE Standard Wheelchairs: R 37 800 Standard Wheelchairs: R 32 180 Standard Wheelchairs: R 17 710 Baby Apnoea monitors: R 1 730
Baby Apnoea monitors: R 1 730
WHEELCHAIRS - 3 YEAR CYCLE Insulin Pumps: R 37 800 Insulin Pumps: R 32 830 Insulin Pumps: R 29 050 Breast pumps: R 2 920
Breast pumps: R 2 920
INSULIN PUMPS, SUBJECT TO Other external appliances: R 12 640 Other external appliances: R 10 750 Other external appliances: R 6 320
PRE-AUTHORISATION - 4 YEAR CYCLE Baby Apnoea monitors: R 1 945 Baby Apnoea monitors: R 1 945 Baby Apnoea monitors: R 1 945
Breast pumps: R 3 240 Breast pumps: R 3 240 Breast pumps: R 3 240
NEW R10 million per beneficiary per journey R10 million per beneficiary per journey R10 million per beneficiary per journey R10 million per beneficiary per journey R10 million per beneficiary per journey R10 million per beneficiary per journey
for emergency medical costs while for emergency medical costs while for emergency medical costs while you for emergency medical costs while for emergency medical costs while for emergency medical costs while
you travel outside South Africa. This you travel outside South Africa. This travel outside South Africa. This cover you travel outside South Africa. This you travel outside South Africa. This you travel outside South Africa. This
INTERNATIONAL TRAVEL COVER
cover is for a period of 90 days from cover is for a period of 90 days from is for a period of 90 days from your de- cover is for a period of 90 days from cover is for a period of 90 days from cover is for a period of 90 days from
your departure from South Africa. Pre- your departure from South Africa. Pre- parture from South Africa. Pre-existing your departure from South Africa. Pre- your departure from South Africa. Pre- your departure from South Africa. Pre-
existing conditions are excluded. existing conditions are excluded. conditions are excluded. existing conditions are excluded. existing conditions are excluded. existing conditions are excluded.
Unlimited - Subject to Netcare 911 Unlimited - Subject to Netcare 911 Unlimited - Subject to Netcare 911 Unlimited - Subject to Netcare 911 Unlimited - Subject to Netcare 911 Unlimited - Subject to Netcare 911
NETCARE 911 EMERGENCY SERVICES
authorisation authorisation authorisation authorisation authorisation authorisation
ALLIANCE DOUBLE PLUS VITAL ESSENTIAL PLUS FIRST CHOICE NETWORK CHOICE
All benefits listed below are annual, unless otherwise stated. Where a condition qualifies as a PMB and is registered with the Scheme, payment will be governed by the legislation set out in the Regulations listed in the Medical Schemes Act.
OTHER BENEFITS (per Beneficiary) SUBJECT TO THE ANNUAL OVERALL DAY-TO-DAY BENEFIT LIMIT
Annual overall limit: Beneficiary specific
DAY TO DAY BENEFITS Annual Overall Limits Annual Overall Limits limits:
Limited to funds available in the
BENEFITS BELOW ARE SUBJECT TO THE Adult R 23 870 Adult R 9 340 No Benefit (a) Medicines R 2 330
beneficiarys Medical Savings Account
OVERALL ANNUAL LIMIT Child R 15 000 Child R 6 530 (b) Advanced Dentistry R 5 040
(c) Other R 2 330
General practitioner consultations: 10 per
GPS, SPECIALISTS AND DENTISTS beneficiary through a DSP
Specialist consultations: 100% CBT limited to
CONSULTATIONS, PROCEDURES AND 80% CBT
80% CBT 80% CBT No Benefit Subject to Medical Savings Account R7 420 per family
RADIOLOGY PERFORMED BY THESE Subject to limit (c)
Basic dentistry: 100% Scheme Tariff at
PRACTITIONERS; BASIC DENTISTRY network provider only limited to R 2,400
per beneficiary
100% SEP plus a dispensing fee for basic
ACUTE MEDICATION 80% SEP plus a dispensing fee, subject formulary and 80% SEP plus dispensing
80% SEP plus a dispensing fee 80% SEP plus a dispensing fee No Benefit Subject to Medical Savings Account
INCLUDING INJECTIONS AND MATERIALS to MMAP. Subject to limit (a) fee for extended formulary, both subject
to MMAP
NON-DSP VISITS One non-network visit per beneficiary or
Not applicable Not applicable Not applicable Not applicable Not applicable
TO DOCTORS ROOMS two per family, 20% co-payment
AND One casualty visit per family
CASUALTY AND OUT PATIENT TREATMENT
Medication: 80% SEP plus a dispensing (facility fee, consumed meds and
AT A HOSPITAL materials). Limited to R 1 210.
80% CBT 80% CBT No Benefit Subject to Medical Savings Account fee subject to limit (a)
ALL MEDICATIONS WILL BE PAID OUT OF Treatment: 80% CBT subject to limit (c) Associated claims such as radiology and
ACUTE MEDICATION BENEFIT pathology are not included.
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, Occupational therapy and
80% CBT subject to sub-limit R 1 270 physiotherapy only 100% CBT limited
HOMOEOPATHS, OCCUPATIONAL THERAPY, 80% CBT 80% CBT No Benefit Subject to Medical Savings Account
Subject to limit (c) to R 2 020 per beneficiary on referral
PHYSIOTHERAPISTS, PODIATRY AND from DSP only
SPEECH THERAPY
BENEFIT SPECIFIC LIMITS
80% CBT limited to: 80% CBT limited to:
ADVANCED DENTISTRY Mo R 12 520 Mo R 9 340 50% CBT
100% of CBT at network provider only,
CROWNS, BRIDGES, ORTHODONTICS, M1 R 18 730 M1 R 13 380 No Benefit Subject to Medical Savings Account Subject to limit (b) excluding dental
limited to R 2 910 per beneficiary
DENTURES M2+ R 22 470 M2+ R 18 080 implants
Subject to Annual Benefits Subject to Annual Benefits
80% SEP plus a dispensing fee, subject
80% SEP plus a dispensing fee, limited 80% SEP plus a dispensing fee, limited 80% SEP plus a dispensing fee, subject to
OVER THE COUNTER MEDICATION No Benefit Subject to Medical Savings Account to MMAP, limited to R 1 315 per
to R 3 150 per beneficiary to R 1 390 per beneficiary MMAP, limited to R820 per beneficiary
beneficiary. Subject to limit (a)
LASER K
NO APPROVAL FOR SURGERY WHERE
80% CBT limited to R9 450 per eye 80% CBT limited to R3 510 per eye No Benefit Subject to Medical Savings Account No Benefit No Benefit
SPECTACLES OBTAINED IN PREVIOUS
12 MONTHS
ANTE-NATAL FOETAL SCANS
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
PER PREGNANCY
ANTE-NATAL CLASSES
80% CBT limited to R1 890 per 80% CBT limited to R1 390 per 80% CBT subject to sub-limit R815
SUBJECT TO ENROLMENT ON THE No Benefit Subject to Medical Savings Account No Benefit
pregnancy pregnancy Subject to limit (c)
MOTHER-TO-BE PROGRAMME
Consultation: See Preventative The benefit PER BENEFICIARY at a PPN provider would be as follows:
Consultation: See Preventative Wellness For the benefit cycle of 24 months from date of claiming, each beneficiary is entitled to:
Wellness
Add ons R 820 One Composite Consultation inclusive of a Refraction, Tonometry and Visual Field screening AND
Add ons R 1 000 EITHER SPECTACLES - A PPN Frame to the value of R150 or R550 off any alternative frame and/or lens
Single vision R 820 OR
SPECTACLES AND LENSES Single vision R 1 260 OR
Bifocal R 2 220 OR enhancements and one pair of lenses: either One pair of Clear Aquity Single Vision; Clear Aquity Bifocal
Bifocal R 2 530 OR Consultation: lenses or Clear Aquity Multifocal lenses OR CONTACT LENSES - Contact lenses to the value of R750.
FROM OPTOMETRIST ONLY ANNUAL BENEFIT, Varifocal R 3 410 AND Subject to Medical Savings Account The benefit PER BENEFICIARY at a NON PPN provider would be as follows:
Varifocal R 3 800 AND Part of Preventative Wellness
UNLESS OTHERWISE STATED Frames Frames R 2 280 OR One consultation per Beneficiary during the Benefit Cycle, limited to a maximum cost of R635 AND
R 5 020 OR
Contact lenses R 3 150 EITHER SPECTACLES - A frame benefit of R550 towards the cost of a frame and/or lens enhancements
Contact lenses R 6 320
Lenses, frames etc 80% Optical Assistant and one pair of lenses: either one pair of clear single vision spectacle lenses limited to R150 per lens
Lenses, frames etc 80% Optical Assistant or one pair of clear flat top bifocal spectacle lenses limited to R325 per lens or one pair of clear flat top
Rates
Rates Multifocal lenses limited to R570 per lens OR CONTACT LENSES - Contact Lenses to the value of R750.
MONTHLY CONTRIBUTION RATES

ALLIANCE DOUBLE PLUS VITAL ESSENTIAL PLUS FIRST CHOICE NETWORK CHOICE
Monthly Risk Contribution Monthly Risk Contribution Total Monthly Contribution Monthly Risk Contribution Income Category Total Income Category
monthly
Adult R 3 600 Adult R 2 384 Adult R 1 540 Principal R 1 191 contribution
Child R 2 018 Child R 1 408 Child R 828 Adult R 947 R 0 - R 7 240 R 0 - R 14 000
Child R 570 Adult R 679 Principal R 1 025
Monthly MSA Contribution Monthly MSA Contribution Child R 400 Adult R 860
Monthly MSA Contribution 1st Child R 455
Adult R 464 Adult R 303 R 7 241 - R 14 000 (rest are free)
Child R 221 Child R 197 Principal R 395 Adult R 1 077
Adult R 315 Child R 621 R 14 001 - R 18 070
Total Monthly Contribution Total Monthly Contribution Child R 190 Principal R 1 190
R 14 001 - R 19 830 Adult R 950
Adult R 1 610 Child R 550
Adult R 4 064 Adult R 2 687 Total Monthly Contribution Child R 916
Child R 2 239 Child R 1 605 R 18 071 - R29 750
Principal R 1 586 R 19 831 + Principal R 1 445
Adult R 1 262 Adult R 2 006 Adult R 1 125
Child R 760 Child R 1 279 Child R 743
R 29 751+
Principal R 1 925
Adult R 1 562
Child R 973
GLOSSARY
* More details available on the website www.camaf.co.za - for full explanations, consult the Registered Rules
ADULT Refers to the member and dependants who are 22 or older at any time in the year of cover.
CAMAF 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
CBT
% paid on different options.
Chronic Disease List - the list of PMBs includes 27 common chronic conditions called CDLs. Schemes must provide cover for the diagnosis, treatment and care of these conditions. Members must register
CDL
their conditions to qualify for benefits. Schemes can provide protocols in terms of the range (RP and Formularies) and delivery of medication (DSPs).
Condition Medicine List - once a patients 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.
CML/ FORMULARY
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.
The 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
DSP
Choice, Pharmacy networks for all chronic medications and Netcare hospital group for Network Choice hospital admissions.
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 f orm of Diagnosis Treatment Pairs (DTPs). A D TP 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
DTP
include the cost of 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 (DSPs).
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
ICD 10 CODE 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.
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
MEDICAL SAVINGS
extension when an overall benefit has been exceeded
ACCOUNT
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.
Maximum 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
MMAP
(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.
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 DTPs)
PMB
27 chronic conditions defined in the CDL
These costs may not be paid from the members savings benefit and cost saving measures can be used by way of utilising
DSPs, Reference Pricing and Formularies.
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
PRE-AUTHORISATION
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.
Means 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
PROTOCOL
management guidelines.
RISK CONTRIBUTIONS Those funds allocated to the overall pool of funds for the payment of all claims other than those paid from the Medical Savings Account.
Reference Pricing is the maximum price for which the Scheme will be liable for specific medicine or classes of medicine, listed on the Schemes Condition Medicine List (CML). The reference price varies per
RP
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 RATE The 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.
SEP Single 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.