CATEGORY B:
DAY TO DAY BENEFITS
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COVER
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Sub-limits are pro-rated from date of joining,
except Optical Benefit.
OVERALL ANNUAL LIMIT
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%
NAMAF TARIFF
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21.
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General Practitioners & Specialists
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Limited to N$16 500 per Family
Limited to N$8 500 per Beneficiary
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21.1 Consultations/Visits (out-of-hospital, including casualties)
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100%
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Sub-limit 21
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21.2 Procedures/Services (out-of-hospital)
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100%
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Sub-limit 21
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21.3 Materials and Disposable Items
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100%
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Sub-limit 21
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21.4 Radiology & Pathology
(Referral from Medical Practitioner)
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100%
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Sub-limit 21
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Benefit Booster applicable
(Additional benefit once limit is exceeded)
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Refer to Sub-limit 31
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22.
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Dentistry
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Limited to N$8 750 per Beneficiary (excluding Orthodontics benefit)
Limited to N$11 500 per Family (excluding Orthodontics benefit)
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22.1 Basic Dentistry
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100%
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Sub-limit 22
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22.2 Specialised / Advanced Dentistry
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100%
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Sub-limit 22
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22.3 Dental Implants
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22.3.1 Consultation & Procedure (in-hospital)
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100%
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Limited to N$11 500 per Family
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22.3.2 Consultation & Procedure (in-Practice)
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150%
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Limited to N$15 000 per Family
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22.3.3 Implant Component
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100%
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Limited to N$5 250 per Beneficiary
Limited to N$11 500 per Family
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Benefit Booster applicable
(Additional benefit once limit is exceeded)
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Refer to Sub-limit 30
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22.4 Orthodontics
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100%
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Limited to N$12 250 per Beneficiary (once-off benefit)
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23.
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Medicine & Injections
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80%
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Limited to N$15 750 per Beneficiary
Limited to N$29 750 per Family
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23.1 Acute Medicine
Paid at Maximum Namibia Medicine Price List on generics
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Limited to N$5 750 per Beneficiary
Limited to N$12 250 per Family
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23.2 Chronic Medicine
Paid at Maximum Namibia Medicine Price List on generics
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80%
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Limited to N$8 750 per Beneficiary
Limited to N$15 550 per Family
Sub-limit 23
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23.3 Chronic Medicine (Pensioners)
Paid at Maximum Namibia Medicine Price List on generics
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100%
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Limited to N$8 750 per Beneficiary Limited to N$15 550 per Family Sub-limit 23
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23.4 Essential Vaccination/Immunization
(As per WHO Guidelines)
Paid at Maximum Namibia Medicine Price List on generics
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100%
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Sub-limit 23
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Benefit Booster applicable
(Additional benefit once limit is exceeded)
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Refer to Sub-limit 31
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23.5 Self Medication
Paid at Maximum Namibia Medicine Price List on generics
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100%
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Limited to N$1 250 per Beneficiary
Limited to N$1 950 per Family
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Limited to N$180 per script per beneficiary per day
Sub-limit 23
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24.
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Specified Illness Conditions (Subject to pre-authorisation)
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Limited to N$32 500 per Beneficiary
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24.1 HIV/AIDS
(As per National Guidelines for Antiretroviral Therapy)
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24.1.1 Medicine
Paid at Maximum Namibia Medicine Price List on generics
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100%
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Sub-limit 24
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24.1.2 First Full HIV Consultation / Assessment
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N$440
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Once off benefit Sub-limit 24
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24.1.3 Consultation (after the first full HIV consultation / assessment)
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N$405
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Limited to 6 consultations per Beneficiary
Sub-limit 24
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24.1.4 HIV Counselling
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100%
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Limited to N$1 300 per Beneficiary
Sub-limit 24
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24.1.5 Pathology Tests
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100%
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Sub-limit 24
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24.1.6. HIV Resistance Test
(Subject pre-authorisation)
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100%
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Sub-limit 24
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24.2 Prevention of Mother-to-Child Transmission (PMTCT)
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100%
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Sub-limit 24
As per National Guidelines
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24.3 Post-Exposure Prophylaxis (PEP)
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100%
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Sub-limit 24
As per National Guidelines
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24.4 Pre-Exposure Prophylaxis (PrEP)
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100%
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Sub-limit 24
As per National Guidelines
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25.
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Primary Health Care Services
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Limited to N$ 400 pr Beneficiary Limited to N$ 1 200 per Family
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25.1 Consultations & Procedures
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100%
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Sub-limit 25
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25.2 Medicine & Injections
Paid at Maximum Namibia Medicine Price List on generics
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80%
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Sub-limit 23.1
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Benefit Booster applicable
(Additional benefit once limit is exceeded)
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Refer to Sub-limit 32
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26.
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Auxiliary Services (Supplementary Services)
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Limited to N$10 000 per Beneficiary
Limited to N$12 500 per Family
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| 26.1 Art Therapy
| 100%
| Sub-limit 26
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| 26.2 Audiology / Speech Therapy
| 100%
| Sub-limit 26
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26.3 Biokinetics
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100%
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Limited to N$3 750 per beneficiary
Sub-limit 26
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| 26.4 Chinese Medicine
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| No benefit
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| 26.5 Chiropractor 26.5.1 Consultation & Procedure
| 100%
| Sub-limit 26
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| 26.5.2 Medicine
| 80%
| Sub-limit 23.1
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26.6 Clinical Psychology / Psychological Counsellor
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100%
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Limited to N$3 750 per beneficiary
Sub-limit 26
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26.7 Clinical Technology
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100%
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Sub-limit 26
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26.8 Dietician
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100%
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Sub-limit 26
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26.9 Hearing Aid Acoustician
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100%
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Sub-limit 26
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26.10 Homeopathy/Naturopathy/ Phytotherapy
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100% |
Sub-limit 26
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26.10.1 Consultation & Procedure
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100%
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Sub-limit 26 |
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26.10.2 Medicine
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80%
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Sub-limit 23.1
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26.11 Occupational Therapy
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100%
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Sub-limit 26
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25.12 Orthotist / Proshetist
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100%
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Sub-limit 26
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26.13 Physiotherapy
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100%
| Limited to N$3 750 er Beneficiary Sub-limit 26
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26.14 Podiatry / Chiropody
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100%
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Sub-limit 26
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26.15 Social Worker
(Motivation required)
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100%
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Limited to N$3 750 per beneficiary
Sub-limit 26
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Benefit Booster applicable
(Additional benefit once limit is exceeded)
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Refer to Sub-limit 31
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27.
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Wheelchair
(Subject to prior approval)
- Inclusive of repair & maintenance
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100% of cost
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Limited to N$8 500 per Beneficiary every 4 years (2019/2022)
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28.
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Appliances (External)
(Subject to MHC guidelines)
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80%
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Limited to N$3 750 per family
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29.
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Hearing Aids Apparatus
(Subject to prior approval)
- Inclusive of repair & maintenance
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100% of cost
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Limited to N$20 000 per Family every 2 years (2020/2021)
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30.
| Medical Devices for Diabetes Management (Subject to prior approval and MHC guidelines)
| 100%
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| 30.1 Insulin Pumps / Glucose Monitoring Kit / Glucose Reader
| 80% of cost
| Limited to N$ 35 000 per Beneficiary every 4 years (2020/2023)
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| 30.2 Diabetes Related Consumables
| 80% of cost
| Limited to N$ 2 000 Beneficiary
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31.
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Optical
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N$3 250 per Beneficiary limited to every 2 years (including frames) (2019/2020)
N$6 500 per Family (including frames) (2019/2020)
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31.1 Eye Test
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100%
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Limited to one eye test per Beneficiary per annum
Sub-limit 31
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31.2 Contact lenses/Spectacle lenses
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100%
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Sub-limit 31
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| 31.3 Bi-focal / Multi-focal lenses
| 100%
| N$700 per Beneficiary limited to every 2 years (in addition to sub-limit 31) (2019/2020)
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31.4 Frame
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100% of cost
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Limited to N$1 000 per Beneficiary
Sub-limit 31
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32.
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Benefit Booster
Applicable if Medicine & Injections, Dentistry, GP’s & Specialists, Primary Health Care and Auxiliary Services benefits are depleted
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Limited to N$2 350 per Beneficiary
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32.1 Medicine & Injections (Acute & Chronic)
- Excluding Self-Medication
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70%
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Sub-limit 32
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32.2 Medicine & Injections (Chronic Pensioner)
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90%
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Sub-limit 32
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32.3 Dentistry & Dental Implants (Excluding Orthodontic)
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70%
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Sub-limit 32
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32.4 General Practitioners & Specialists (Consultations/Visits & Procedures/Services out-of-hospital, including casualties)
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80%
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Sub-limit 32
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32.5 Primary Health Care
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80%
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Sub-limit 32
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32.6 Auxiliary Services
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70%
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Sub-limit 32
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33.
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Health SmartCard
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No Additional Costs. Each Dependent will receive his/her own Smartcard. Benefits can be verified at Service Providers 24/7. In case of Emergency, Member and Dependents can be identified without Health Smartcard. Next of Kin can be contacted immediately.
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