DISCOVERY - HEALTH PLAN GUIDE 2019

 
DISCOVERY - HEALTH PLAN GUIDE 2019
2019

 D I S C O V E R Y H E A LT H M E D I C A L S C H E M E

HEALTH PLAN GUIDE
DISCOVERY - HEALTH PLAN GUIDE 2019
Discovery Health Medical Scheme
For complete                                                                                                                                                                                                                                                                                                                                                           Join SA’s leading medical aid

peace of mind                                                                                                                                                                                                                                                                                                                                                          Discovery Health Medical Scheme gives you complete peace of mind that
                                                                                                                                                                                                                                                                                                                                                                       your healthcare is in good hands at every stage of your health journey

                                                                                                                                                                                                                                                                                                                                                                                           01
                                                                                                                                                                                                                                                                                                                                                                                   Widest range of plans
                                                                                                                                                                                                                                                                                                                                                                                      to choose from
                                                                                                                                                                                                                                                                                                                                                                                                                                                                     02
                                                                                                                                                                                                                                                                                                                                                                                                                                                             Rich benefits tailored
                                                                                                                                                                                                                                                                                                                                                                                                                                                             to your health needs

                                                                                                                                                                                                                                                                                                                                                                            Choose from 23 health plan options                                        Unmatched benefits with unlimited
                                                                                                                                                                                                                                                                                                                                                                           designed to suit your individual health                                    private hospital cover and full cover
                                                                                                                                                                                                                                                                                                                                                                                    and financial needs                                                         in our networks

                                                                                                                                                                                                                                                                                                                                                                                           03
                                                                                                                                                                                                                                                                                                                                                                                    Real value through
                                                                                                                                                                                                                                                                                                                                                                                 affordable contributions
                                                                                                                                                                                                                                                                                                                                                                                                                                                                     04
                                                                                                                                                                                                                                                                                                                                                                                                                                                                Highest financial
                                                                                                                                                                                                                                                                                                                                                                                                                                                                 stability rating

                                                                                                                                                                                                                                                                                                                                                                                Contributions are on average                                              Our industry-leading financial
                                                                                                                                                                                                                                                                                                                                                                                  16.4% lower than other                                                  stability means you can have
                                                                                                                                                                                                                                                                                                                                                                                 South African medical aids                                                 complete peace of mind

                                                                                                                                                                                                                                                                                                                                                                                           05
                                                                                                                                                                                                                                                                                                                                                                              Access to the most advanced
                                                                                                                                                                                                                                                                                                                                                                                digital health technology
                                                                                                                                                                                                                                                                                                                                                                                                                                                                     06
                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Get rewarded
                                                                                                                                                                                                                                                                                                                                                                                                                                                                for being healthy

                                                                                                                                                                                                                                                                                                                                                                                Seamless support is just one                                              You have access to the world’s
                                                                                                                                                                                                                                                                                                                                                                               click away for you at every step                                                leading science-based
                                                                                                                                                                                                                                                                                                                                                                                  of your healthcare journey                                               wellness programme, Vitality

The benefits explained in this brochure are provided by Discovery Health Medical Scheme, registration number 1125, administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. This brochure is only a summary of the key benefits and features of Discovery Health Medical Scheme plans, awaiting      Vitality is a separate wellness product sold and administered by Discovery Vitality (Pty) Ltd, registration number 1999/007736/07,
formal approval from the Council for Medical Schemes. In all instances, Discovery Health Medical Scheme Rules prevail. Please consult the Scheme Rules on www.discovery.co.za. When reference is made in this brochure to “we” in the context of benefits, members, payments or cover, this refers to Discovery Health Medical Scheme. We are continuously improving   an authorised financial services provider.
our communication to you. The latest version of this guide as well as detailed benefit information is available on www.discovery.co.za.                                                                                                                                                                                                                                Reference to the lower cost analysis is a comparison of our contributions with those of open scheme competitors, based
                                                                                                                                                                                                                                                                                                                                                                       on an internal analysis of publicly available marketing material.
DISCOVERY - HEALTH PLAN GUIDE 2019
DISCOVERY HEALTH MEDICAL SCHEME

  A world of digital support is one click away                                                                                                                                                  Easily find doctors and hospitals                                                                                                                                                         Track your health
                                                                                                                                                                                                Get the best care                                                                                                                                                                         Get rewarded for managing your health
                                                                                                                                                                                                	Fully interactive, real time technology that helps you find doctors and hospitals,                                                                                                     	Follow personalised health checks, recommended for you,
                                                                                                                                                                                                   on our networks, near you                                                                                                                                                                 to help you track and manage your health
Manage your health plan anywhere, anytime, in the palm of your hand
                                                                                                                                                                                                 	Give your doctor consent to view your health records before your consultation                                                                                                          	You will also get tips on how you can improve your weight,
                                                                                                                                                                                                                                                                                                                                                                                             nutrition and exercise levels and get rewarded along the way
                                                                                                                                                                                                	Choose a doctor that suits your needs, view the doctor’s practice information
        Ask Discovery                                                                                                                                                                              to schedule your appointment
        	Our chat bot powered by artificial intelligence is available 24/7                                                                                                                    	Book a follow-up video consultation with your
           to provide instant answers online                                                                                                                                                       doctor at your convenience
        	If you need an important document or need to know about
           your benefits, start a conversation by saying Hello, and Ask                                                                             Doctor advice on your device
           Discovery will process your request or answer your question
                                                                                                                                                    Anywhere anytime                                                                                                                                                                                                                                               Your medicine comes to you
                                                                                                                                                    	When it’s simply not possible to                                                                                                                                                                                                                            No queues, no fuss
                                                                                                                                                       see your doctor, get trusted advice
                                                                                                                                                                                                                                                                                                                                                                                                                   	Order your medicine on the Discovery
                                                                                                                                                       from doctors on the Discovery App
                                                                                                                                                                                                                                                                                                                                                                                                                      app from MedXpress and have it
                                                                                                                                                       at no additional cost
                                                                                                                                                                                                                                                                                                                                                                                                                      delivered to your door, or collect
          Manage your health                                                      Download key documents                                                                                                                                                                                                                                                                                                              at a network pharmacy near you

          Proactive support                                                       Hassle free admin
          	Understand your health risks                                         	Download your tax certificates
             with MyFamilyHistory and                                                and international travel documents
             access progress dashboards                                              when you need them
             for specific chronic conditions                                                                                                                             Manage benefits and track claims                                                                                                                                                          Never forget to take your medicine
                                                                                  	View information on hospital
          	Unlock additional benefits when                                         procedures for your authorised                                                      Real time, on the go                                                                                                                                                                      Get reminders on your phone
             you are pregnant and after your                                         hospital admissions
                                                                                                                                                                         	Submit and track your claims and benefits                                                                                                                                              	Stay on track with your prescribed medicine
             baby is born
                                                                                                                                                                            real time
                                                                                                                                                                                                                                                                                                                                                                    	Get monthly reminders to refill your prescription
                                                                                                                                                                         	KeyCare members can also confirm plan
                                                                                                                                                                            benefits by simply dialling *120*DISCO#
                                                                                                                                                                            or *120*34726#

                                                                                                                                                                                                                                                                                                                                                             Download the Discovery app or visit www.discovery.co.za

 06
      Discovery Health Medical Scheme, registration number 1125, administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes. Vitality is a separate wellness product sold and administered by Discovery Vitality (Pty) Ltd,   Track your health and associated rewards are brought to you by Discovery Health (Pty) Ltd, registration number 1997/013480/07,
      registration number 1999/007736/07, an authorised financial services provider. Ask Discovery, DrConnect, HealthID, MedXpress, MyFamilyHistory and the Discovery app are brought to you by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider and administrator                                                      an authorised financial services provider and administrator of medical schemes.
      of medical schemes. Visit www.discovery.co.za or click on find a provider in the Discovery app to find hospitals or providers in our network.
DISCOVERY - HEALTH PLAN GUIDE 2019
DISCOVERY HEALTH MEDICAL SCHEME

     Benefits tailored
     to the plan you choose                                                                                                                                                                                                                                                                          Above Threshold Benefit (ATB)
                                                                                                                                                                                                                                                                                                     Certain plans have an Above Threshold Benefit (ATB) that gives you
                                                                                                                                                                                                                                                                                                     further day-to-day cover once you have reached your Annual Threshold.
                                                                                                                                                                                                                   ve
                                                                                                                                                                                                               Abo old
                                                                                                                                                                                                                  sh
Hospital Benefit                                                                                                                                                                                              Thre efit

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                                                                                                                                                                                                                Ben

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                                                                                                                                                                           Ho

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                                                                                                                                                                                sp
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There is no overall limit for hospital cover on any of the Discovery Health

                                                                                                                                                                                                                                      ity
                                                                                                                                                                                         lB
                                                                                                                                                                                             en                                                                                                      Day-to-day Extender Benefit (DEB)

                                                                                                                                                                                                                                           Be
Medical Scheme plans. You can go to any private hospital on most plans.                                                                                                                             efi

                                                                                                                                                                                                                                             ne
                                                                                                                                                                                                          t

                                                                                                                                                                                                                                               fit
                                                                                                                                                           Ch                                                         day                                                                            On selected plans, when you have spent your annual Medical Savings
                                                                                                                                                                                                                 -to-
                                                                                                                                                              ro
                                                                                                                                                                ni                                            Day nder
                                                                                                                                                                     cI                                          t e                                                                                 Account (MSA) allocation, the Day-to-day Extender Benefit (DEB) extends
                                                                                                                                                                          lln                                  Ex efit
                                                                                                                                                                             es                                 Ben
                                                                                                                                                                                sB                                                                                                                   your day-to-day cover for essential healthcare services in our network.
Chronic Illness Benefit (CIB)                                                                                                                  Sc
                                                                                                                                                                                        en
                                                                                                                                                                                          efi
                                                                                                                                                    re                                          t
                                                                                                                                                      en
                                                                                                                                                         in
All our plans cover approved medicine for the Prescribed Minimum Benefit                                                                                   ga                                                                                        t
                                                                                                                                                                nd                                                                             oun
                                                                                                                                                                                                                                            Acc

                                                                                                                                                Vit
Chronic Disease List conditions. Certain plans cover additional conditions.                                                                                          Pr                                                                gs
                                                                                                                                                                       ev
                                                                                                                                                                            en                                              al S
                                                                                                                                                                                                                                a  vin                                                               Maternity Benefit
                                                                                                                                                           ali
                                                                                                                                                                                  tio                                  dic
                                                                                                                                                                                                                    Me

                                                                                                                                                                                                                                            ity
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                                                                                                                                                                                                                                                                                                     You get comprehensive benefits for maternity and early childhood

                                                                                                                                                                                                                                    i t a l                                                          that cover certain healthcare services before and after birth..
Screening and Prevention
                                                                                                                                                                                                                              V
Screening and prevention benefits cover vital tests
to detect early warning signs of serious illness.
                                                                                                                                                                                                                                                                                                     Medical Savings Account (MSA)
                                                                                                                                                                                                                                                                                                     On selected plans, we pay your day-to-day medical expenses from
                                                                                                                                                                                                                                                                                                     the available funds allocated to your Medical Savings Account (MSA).
                                                                                                                                                                                                                                                                                                     This empowers you to manage your spend.

Use our networks to get full cover
                                                                                                                                                                                                                                                              Doctors                                              Medicine
            Hospitals                                                                      Day surgery network
                                                                                                                                                                                                                                                              You have full cover                                  Use MedXpress, or a MedXpress network pharmacy to enjoy
            If you have chosen a plan with a hospital                                      Full cover for a defined list of procedures                                                                                                                        for GPs and specialists                              full cover and avoid co-payments when claiming for chronic
            network, make sure you use a hospital                                          in our day surgery network.                                                                                                                                        who we have payment                                  medicine on the medicine list.
            in that network to get full cover.                                             PG 12 FOR MORE ON T HE DA Y S U RGERY                                                                                                                              arrangements with.                                   P G 15 FOR MORE ON ME D XP RE SS AND MED X P R E SS NE TW OR K
                                                                                           N ET WORK                                                                                                                                                                                                               P H ARMACI E S

08      isit www.discovery.co.za or click on find a provider in the Discovery app to find hospitals or providers in our network. Vitality is not
       V                                                                                                                                                                                                                                          MedXpress is brought to you by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider.   09
       part of Discovery Health Medical Scheme. Vitality is a separate wellness product, sold and administered by Discovery Vitality (Pty)
       Ltd, registration number 1999/007736/07, an authorised financial services provider.
DISCOVERY - HEALTH PLAN GUIDE 2019
DISCOVERY HEALTH MEDICAL SCHEME

     You have unlimited
     hospital cover

All Discovery Health                                Unlimited cover in                                  How we cover your
Medical Scheme plans                                private hospitals                                   hospital and related
offer unlimited hospital                            For any planned or non-emergency                    accounts
cover. Your hospital cover                          admission, you need to contact                      We cover your hospital account
includes the account                                us to confirm your admission.                       from your Hospital Benefit.
from the hospital and                               Some of our plans offer cover for                   Doctors, specialists and other
the accounts from                                   planned admissions in a defined                     healthcare professionals we
your admitting doctor,                              network. These plans include                        have a payment arrangement
anaesthetist and                                    Delta options, Coastal,                             with are covered in full for
                                                    Smart and KeyCare plans.                            approved procedures in
any other approved
                                                                                                        hospital. You benefit from
healthcare professional.                            For planned admissions
                                                    at hospitals outside these                          access to the broadest range
                                                    networks, you either have                           of specialists, which represent
                                                    to pay the full amount or a                         over 90% of our members’
     What is the Discovery                          portion of the hospital account.                    specialist interactions. If you
                                                                                                        use healthcare professionals
     Health Rate (DHR)?                             Some of our plans offer                             that we don’t have payment
     This is a rate set by us.                      full cover for a defined list of                    arrangements with, we will pay
                                                    procedures in our day surgery                       at the rate applicable to your
     We pay for healthcare
                                                    network. An upfront payment                         chosen plan and you may have
     services from hospitals,                       will apply if you choose to have                    a co-payment.
     pharmacies and                                 these procedures performed
     healthcare professionals                       outside the network facilities.

     at this rate.                                  P G 1 2 FOR T HE DEFIN ED
                                                    L I S T OF PROC EDU RES

10
     Visit www.discovery.co.za or click on find a provider in the Discovery app to find hospitals or providers in our network.
DISCOVERY - HEALTH PLAN GUIDE 2019
Emergencies are
                                                                             covered in full
                                                                             If you have an emergency,
                                                                             you can go straight to
                                                                             hospital. If you need
                                                                             medically equipped
Prescribed Minimum Benefit (PMB) conditions                                  transport, call Discovery 911
In terms of the Medical Schemes Act 131 of 1998 and its Regulations,         on 0860 999 911.
all medical schemes have to cover the costs related to the diagnosis,
treatment and care of:

      An emergency medical condition
     A defined list of 270 diagnoses                                     What is an emergency?
      A defined list of 27 chronic conditions.                            An emergency medical condition,
                                                                          also referred to as an emergency,
To access Prescribed Minimum Benefits, there are rules that apply:
                                                                          is the sudden and unexpected
    	Your medical condition must qualify for cover and be part of the    onset of a health condition that
      defined list of Prescribed Minimum Benefit conditions.              requires immediate medical
	The treatment needed must match the treatments in the defined          and surgical treatment. Failure
   benefits.                                                              to provide medical or surgical
	You must use designated service providers (DSPs) in our network.       treatment would result in
   This does not apply in emergencies. However, even in these cases,      serious impairment to bodily
   where appropriate and according to the rules of the Scheme, you        functions or serious dysfunction
   may be transferred to a hospital or other service providers in our     of a bodily organ or part or
   network once your condition has stabilised.                            would place the person’s life
                                                                          in serious jeopardy.
If your treatment doesn’t meet the above criteria, we will pay up to
80% of the Discovery Health Rate (DHR). You will be responsible for the   An emergency does not
difference between what we pay and the actual cost of your treatment.     necessarily require a hospital
                                                                          admission. We may ask you
                                                                          or your treating provider
                                                                          for additional information
                                                                          to confirm the emergency.

                                                                                                           11
DISCOVERY - HEALTH PLAN GUIDE 2019
DISCOVERY HEALTH MEDICAL SCHEME

      You have cover for a defined list
      of procedures in our day surgery network
      On all plans, excluding Executive and Comprehensive plans, we cover the following
      procedures in our day surgery network

Biopsies: Skin*, subcutaneous tissue,               Gastrointestinal                                     	
                                                                                                          Tendon and/or ligament repair,
soft tissue, muscle, bone, lymph, eye,                  Gastrointestinal scopes*                           muscle debridement, fascia procedures
mouth, throat, breast, cervix, vulva,                                                                       (tenotomy, tenodesis, tenolysis,
                                                        (oesophagoscopy, gastroscopy,
prostate, penis, testes                                                                                     repair/reconstruction, capsulotomy,
                                                        colonoscopy, sigmoidoscopy,
                                                        proctoscopy, anoscopy)                              capsulectomy, synovectomy,
Breast*: Mastectomy
                                                                                                            excision tendon sheath lesion,
for gynaecomastia, lumpectomy                        	
                                                      Anorectal procedures (treatment
                                                                                                            fasciotomy, fasciectomy)*. Subject to
(fibroadenoma)                                          of haemorrhoids, fissure, fistula)
                                                                                                            individual case review.
Ear, Nose and Throat                                Gynaecological
     Tonsillectomy and/or adenoidectomy                erclage of uterine cervix
                                                      C                                                     Repair bunion or toe deformity*
      epair nasal turbinates*, nasal septum*,
     R                                               	
                                                      D&C (dilatation and curettage)                        Treatment of simple closed fractures
     ear fistula                                       ndometrial ablation
                                                      E                                                      and/or dislocations, removal of pins
      imple procedures for nose bleed
     S                                                 ysteroscopy
                                                      H
                                                                                                             and plates. Subject to individual case
     (extensive cautery)                                                                                     review
                                                     	
                                                      Sterilisation
      inus procedures* (ethmoidectomy,
     S                                                                                                  Removal of foreign body
                                                       aparoscopic gynaecological
                                                      L
     sinusotomy and lavage)                                                                              	
                                                                                                          Subcutaneous tissue, muscle,
                                                        procedures (aspiration ovarian
      copes (nasal endoscopy*, laryngoscopy)                                                               external auditory canal under general
     S                                                  cyst, myomectomy, salpingectomy,
                                                                                                            anaesthesia
 	
  Middle ear procedures (tympanoplasty,                 fulguration/ablation/lysis of lesions)
     mastoidectomy, myringoplasty,
                                                                                                        Simple superficial
                                                    Incision and Drainage of abscess                    lymphadenectomy
     stapedectomy, myringotomy and/or
     grommets)
                                                    and/or cyst: Skin*, subcutaneous tissue,
                                                    soft tissue, bone, bursa, mouth, tonsil,            Skin: Debridement, removal of lesions*,
     Cochlear implant*                              pilonidal, ovary, Bartholin’s gland, vagina         (dependent on size and diameter), simple
                                                                                                        repair of superficial wound repair
Eye                                                 Orthopaedic
                                                                                                        Urological
     Corneal transplant*                            	
                                                      Arthroscopy, arthrotomy (shoulder,
      ataract surgery
     C                                                  elbow, knee, ankle, hand, wrist, foot,
                                                                                                         	
                                                                                                          Cystoscopy

 	
  Treatment of glaucoma                                 temporomandibular joint), arthrodesis            	
                                                                                                          Removal of ureteral stones

 	
  Other eye procedures (removal of
                                                        (hand, wrist, foot)*                             	
                                                                                                          Repair of bladder prolapse
     foreign body, conjunctival surgery              	
                                                      Minor joint procedures                             	
                                                                                                          Male genital procedures (circumcision,
     (repair laceration, pterygium),                    (intercarpal, carpometacarpal and                   repair of penis, exploration of testes
     glaucoma surgery, probing & repair of              metacarpophalangeal, interphalangeal                and scrotum, orchiectomy,
     tear ducts, vitrectomy, retinal surgery,           joint arthroplasty*)                                epididymectomy, excision hydrocoele,
     eyelid surgery, strabismus repair)                                                                     excision varicocoele, vasectomy)

Ganglionectomy

       * THIS MAY NOT BE A COVERED BENEFIT ON KEYCARE AND ESSENTIAL SMART PLANS, SEE PG 81
12     SEE PG 43, 52, 60 AND 68 FOR THE UPFRONT PAYMENT AMOUNTS FOR ADMISSIONS TO A FACILITY OUTSIDE OF THE NETWORK

   Visit www.discovery.co.za or click on find a provider in the Discovery app to find hospitals or providers in our network.
DISCOVERY - HEALTH PLAN GUIDE 2019
You have cover for
    chronic conditions
    Get the best care and support for your chronic conditions

Prescribed Minimum                                Chronic Illness Benefit                           Medicine cover for the
Benefit (PMB) conditions                          (CIB)                                             Additional Disease List
You have access to treatment                                                                        The Executive and Comprehensive
                                                  The Chronic Illness Benefit
for a list of medical conditions                                                                    plans offer cover for medicine
                                                  (CIB) covers you for a defined
under the Prescribed Minimum                                                                        on the Additional Disease List
                                                  list of chronic conditions.
Benefits (PMBs). The PMBs cover                                                                     (ADL). You are covered up to the
                                                  You need to apply to have
the 27 chronic conditions on                                                                        set monthly CDA for your medicine.
                                                  your medicine covered for
the Chronic Disease List (CDL).                                                                     No medicine list applies.
                                                  your chronic condition.
Our plans offer benefits that
                                                                                                    Extended chronic
are richer than the PMBs.                         Medicine cover for
Cover depends on the plan                                                                           medicine list
                                                  the Chronic Disease List
you choose. To access                                                                               Members on the Executive
PMBs, certain rules apply.                        You get full cover if you use
                                                                                                    Plan also have full cover
                                                  a network provider for approved
                                                                                                    for an exclusive list
PG 1 4 F O R A L I S T                            chronic medicine on our medicine
                                                                                                    of brand medicines.
O F C O NDIT IO N S                               list. For medicine not on our list,
                                                  we cover you up to a set monthly
                                                  rand amount called the Chronic
                                                                                                    How we pay
                                                  Drug Amount (CDA), or the cost                    for medicine
                                                  of the lowest formulary listed                    We pay for medicine up to
                                                  drug on the Smart and KeyCare                     a maximum of the Discovery
                                                  plans. Medicine on KeyCare                        Health Rate (DHR). The DHR
                                                  Start is covered in a state facility.             for medicine is the price
                                                                                                    of the medicine and the
                                                                                                    fee for dispensing it.

                                                                                                                                          13
  Visit www.discovery.co.za or click on find a provider in the Discovery app to find out more about chronic medicine and to find a pharmacy
                                                                                          network provider or MedXpress network pharmacy.
DISCOVERY - HEALTH PLAN GUIDE 2019
DISCOVERY HEALTH MEDICAL SCHEME

                          Chronic conditions                  Additional chronic conditions covered
                         covered on all plans                 on Executive and Comprehensive plans
            Chronic Disease List (CDL) conditions             Additional Disease List (ADL) conditions

                          Addison’s disease, asthma      A   Ankylosing spondylitis

            Bipolar mood disorder, bronchiectasis        B   Behςet’s disease

Cardiac failure, cardiomyopathy, chronic obstructive
 pulmonary disease, chronic renal disease, coronary
                      artery disease, Crohn’s disease
                                                         C   Cystic fibrosis

                                                         D
                  Diabetes insipidus, diabetes Type 1,
                                                             Delusional disorder, dermatopolymyositis
                      diabetes Type 2, dysrhythmia

                                             Epilepsy    E
                                           Glaucoma      G   Generalised anxiety disorder

                                                         H
                 Haemophilia, HIV, hyperlipidaemia,
                                                             Huntington’s disease
                    hypertension, hypothyroidism

                                                         I   Isolated growth hormone deficiency

                                                             Major depression, muscular dystrophy and
                                   Multiple sclerosis    M   other inherited myopathies, myasthenia gravis,
                                                             motor neuron disease

                                                         O   Obsessive compulsive disorder, osteoporosis

                                                             Paget’s disease, panic disorder, polyarteritis
                                 Parkinson’s disease     P   nodosa, post-traumatic stress disorder,
                                                             psoriatic arthritis, pulmonary intestinal fibrosis

                               Rheumatoid arthritis      R
      Schizophrenia, systemic lupus erythematosus        S   Sjögren’s syndrome, systemic sclerosis

                                    Ulcerative colitis   U
                                                         W   Wegener’s granulomatosis

14
DISCOVERY - HEALTH PLAN GUIDE 2019
Where to get your medicine
    Avoid co-payments by using MedXpress and MedXpress Network Pharmacies

What is MedXpress?                                                          MedXpress and MedXpress Network
                                                                            Pharmacies
A convenient medicine ordering service
                                                                            Avoid a 20% co-payment on your chronic medicine
 	Quick, convenient and free delivery when                                 by using these Designated Service Providers (DSPs):
   ordering your medicine through MedXpress                                   Priority, Saver, Core plans and Delta options
                                                                             	
	Use MedXpress to get full cover with no                                    MedXpress or MedXpress Network Pharmacies
   co-payments for medicine on our medicine list                                Smart plans
 	
  Order your medicine online and have it delivered
                                                                            	MedXpress, Clicks or Dis-Chem. MedXpress
  to your door
                                                                              Network Pharmacies do not apply for Smart
    or                                                                        Series members
 	
  Order your medicine online and collect instore                              KeyCare Plus and KeyCare Core plans
  at a MedXpress Network Pharmacy                                           	You must use a network pharmacy or your
    or                                                                        allocated GP.
 	
  Fill a prescription as usual at any MedXpress
  Network Pharmacy                                                          Executive and                         KeyCare Start
 	Reorder your chronic medicine when                                       Comprehensive                         You must use
   it’s convenient for you.                                                 (excluding Delta                      a state facility
                                                                            options) plans
                                                                            You can use any
                                                                            of the pharmacies
    How to order
                                                                            in our pharmacy
             Discovery app                                                  network. You have
                                                                            over 2 500 pharmacies
             or
                                                                            to choose from
              www.discovery.co.za
             or
             medxpress@discovery.co.za

                                                                                                                                           15
MedXpress is brought to you by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider.
                   Visit www.discovery.co.za or click on find a provider in the Discovery app to find hospitals or providers in our network.
DISCOVERY HEALTH MEDICAL SCHEME

     You have access to condition-specific care
     programmes through your Premier Plus GP
     Our condition-specific care programmes together, with your Premier Plus GP,
     help you manage specific conditions

     Premier Plus GP
     A Premier Plus GP is a network GP who has contracted with us to provide you with quality healthcare
     for your condition. You have to be registered on these condition-specific care programmes to
     unlock additional benefits and services. You and your GP can track progress on a personalised
     dashboard to identify the next steps to optimally manage your condition and stay healthy over time.

           HIV Care programme                                       Diabetes Care programme
           If you are registered on the HIV programme,              If you are registered on the Chronic Illness
           you are covered for the care you need, which             Benefit for diabetes, you can join the Diabetes
           includes additional cover for social workers.            Care programme. The programme unlocks
           You can be assured of confidentiality at all             cover for additional consultations with dietitians
           times. You have to see a Premier Plus GP to              and biokineticists. You also have access
           avoid a 20% co-payment (excluding Executive              to a nurse educator to help you with the
           and Comprehensive plans). You need to get                day-to-day management of your condition.
           your medicine from a designated service                  You have to see a Premier Plus GP to avoid
           provider (DSP) to avoid a 20% co-payment.                a 20% co-payment (excluding Executive and
                                                                    Comprehensive plans).
           Cardio Care programme
           If you are registered on the Chronic Illness             Mental Health Care programme
           Benefit for hypertension, hyperlipidaemia
                                                                    If you meet the Scheme’s clinical entry criteria
           and ischaemic heart disease you have
                                                                    you have access to defined cover for the
           access to a defined basket of care and
                                                                    management of episodes of major depression.
           an annual cardiovascular assessment,
                                                                    Enrollment on the programme unlocks cover
           if referred by your Premier Plus GP and
                                                                    for prescribed medicine, and additional GP
           enrolled on the Cardio Care programme.
16                                                                  consultations to allow for effective evaluation,
     Visit www.discovery.co.za or click on find a provider in the   tracking and monitoring of treatment.
     Discovery app to find hospitals or providers in our network.
Track your health
    Get healthier with goals tailored to your specific health needs

If you are at risk of developing or diagnosed with cardiovascular disease or diabetes, we will provide
you with tailored goals you need to take to help you manage your health and track your progress.

Health checks                                                                                               Exercise goals
Tailored recommendations                                                                                    You will get personalised
about general screening tests,                                                                              weekly exercise goals
as well as additional tests you                                                                             to help you get healthy
may need to complete based
on your age, gender
and health profile                                                                                          HealthyFood
Clinical entry criteria may                                                                                 Get recommendations
apply to some of these tests.                                                                               on which foods to buy
SE E PG 2 0 F OR A L I S T                                                                                  more or less of based
O F SC R E E NIN G T ES T S                                                                                 on your food purchasing
T HA T A R E C O V ER ED                                                                                    behaviour
BY THE SC HEME

Medicine tracker                                                                                            Weight
Reminders and prompts to keep                                You will get rewarded                          management
you on track with taking medicine                          for achieving each of your                       A tailored weight loss
on time and as prescribed                              recommended personalised goals                       journey designed to help
                                                                                                            you achieve or maintain
                                                                                                            your recommended
                                                                                                            weight goal

           Download the Discovery app to track your health

                                                                                                                                       17
                                              Track your health and associated rewards are brought to you by Discovery Health (Pty) Ltd,
                    registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
DISCOVERY HEALTH MEDICAL SCHEME

     You have unlimited
     cover for cancer
Oncology Benefit                                                                                                                                                                                                                         Advanced Illness Benefit
If you are diagnosed with cancer and once we have approved your cancer                                                                                                                                                                   Members with cancer have access to a comprehensive
treatment, you are covered by the Oncology Care Programme. We cover                                                                                                                                                                      palliative care programme. This programme offers
                                                                                                                                                              Advanced
your approved cancer treatment over a 12-month cycle.                                                                                                      Illness Benefit                                                                unlimited cover for approved care at home.

On Executive and Comprehensive plans we cover the first R400 000.
On Priority, Saver, Smart and Core plans we cover the first R200 000.                                                                                                                                                                    Extended Oncology Benefit

                                                                                                                                                 fit

                                                                                                                                                           fit

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If your treatment costs more than the cover amount, we will cover up to                                                                                                                                                                  On the Executive and Comprehensive plans you

                                                                                                                                                Be

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                                                                                                                                                              en
80% of the subsequent additional costs, except if the treatment forms                                                                                                                                                                    also have extended cover in full for a defined list of

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                                                                                                                                           mu
part of the extended cover offered on the Comprehensive and Executive

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                                                                                                                                                                                                                                         cancers and treatments that meet the Scheme’s

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plans, which we will cover in full.                                                                                                                                                                                                      criteria.

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                                                                                                                                                      On
                                                                                                                                                                   Oncology Benefit

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On Essential Smart we cover cancer treatment in our network.

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                                                                                                                                                                                                                                         Oncology Innovation Benefit

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All cancer-related healthcare services are covered up to 100% of the

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                                                                                                                                                 te
                                                                                                                                       On

                                                                                                                                                Ex
                                                                                                                                 Pr
Discovery Health Rate (DHR). You might have a co-payment if your                                                                                                                                                                         On the Executive and Comprehensive Plans you have
healthcare professional charges above this rate.                                                                                                                                                                                         cover for a defined list of innovative cancer medicines
                                                                                                                                  Screening and Prevention                                                                               that meet the Scheme’s criteria. You will need to pay
Prescribed Minimum Benefits (PMB)                                                                                                                                                                                                        25% of the cost of these treatments.

Cancer treatment that is a Prescribed Minimum Benefit (PMB), is always
covered in full. On the KeyCare plans we cover cancer treatment in our
network, or in a state facility if you are on KeyCare Start. If you choose
to use any other provider, we will only cover up to 80% of the DHR.

                                                                                                                                                                                     You need to get your approved oncology medicine on our medicine list from a Designated Service
                                                                                                                                                                                     Provider (DSP) to avoid a 20% co-payment. Speak to your treating doctor to confirm that they are
                                                                                                                                                                                     using our DSPs for your medicine and treatment received in rooms or at a treatment facility.

18                                                                                                                                                                                                                                                                                            19
     Visit www.discovery.co.za or click on find a provider in the Discovery app to find hospitals or providers in our network.
DISCOVERY HEALTH MEDICAL SCHEME

     You get screening and prevention benefits
     Preventive screening is important to ensure that medical conditions are detected early

As a Discovery Health Medical Scheme member, you have access to screening
and prevention benefits at any one of our wellness providers

          Screening for adults                                                            You may qualify for the

          The Screening and Prevention Benefit covers certain tests such
                                                                                          following additional tests:
          as blood glucose, blood pressure, cholesterol, body mass index
          and HIV screening at one of our wellness providers.                                Defined diabetes and
                                                                                             cholesterol screening tests
          We also cover a mammogram every two years, a Pap smear once
          every three years and a PSA test (prostate screening) each year.                	Breast MRI or mammogram
                                                                                             and once-off BRCA testing
          Screening for kids                                                                 for breast screening
                                                                                          	Pap smear for cervical
          This benefit covers growth assessment tests, including height,
                                                                                             screening
          weight, head circumference and health and milestone tracking
          at any one of our wellness providers.                                               easonal flu vaccine
                                                                                             S
                                                                                             for members:

          How we pay                                                                         – during pregnancy
                                                                                             – 65 years or older
          These tests and consultations do not affect your day-to-day
          benefits as they are paid from the Screening and Prevention                        –	registered for certain
          Benefit. Consultations that do not form part of PMBs will                             chronic conditions
          be paid from your available day-to-day benefits.

                                                      Clinical entry criteria may apply to some of these tests.
                                                      Visit www.discovery.co.za to find out more.

20
     Visit www.discovery.co.za to find screening providers in our network.
You get cover for day-to-day
   medical expenses
Medical Savings Account (MSA)                           Above Threshold Benefit (ATB)
Available on the Executive, Comprehensive,              Available on the Executive, Comprehensive
Priority and Saver plans                                and Priority plans

We pay your day-to-day medical expenses such as         Once the claims you have sent to us add up to
GP and specialist consultations, medicine, except for   the Annual Threshold, we pay the rest of your claims
registered and approved chronic medicine, radiology     from the Above Threshold Benefit (ATB), at the DHR
and pathology from the available funds allocated        or a portion of it. The Executive and Comprehensive
to your MSA. Any unused funds will carry over           plans have an unlimited ATB, and the Priority plans
to the next year.                                       have a limited ATB.

On the Executive, Comprehensive and Priority plans,
when you run out of MSA, you will have to pay for
                                                        Cover for day-to-day expenses
some healthcare expenses from your pocket before        on other plans
you reach your Annual Threshold. This is called the     The Smart plans offer unlimited cover for GP
Self-Payment Gap (SPG).                                 consultations and other day-to-day benefits
                                                        with fixed co-payments in the Smart Network.

   When you are in your Self-Payment Gap                The KeyCare Plus and Start plans offer primary care
                                                        cover through your chosen GP.
   (SPG) you must still send your claims to us
   so that we know when to start paying from            On Core and KeyCare Core plans, you will have
                                                        to pay for any day-to-day expenses.
   your Above Threshold Benefit (ATB)

                                                        Maternity and early childhood benefits
Day-to-day Extender Benefit (DEB)                       All plans offer comprehensive healthcare services
                                                        for maternity and early childhood paid for by the
Use a network GP on HealthID who meets the digital
                                                        Scheme. These benefits will not affect your day-to-
criteria to access the Day-to-day Extender Benefit
                                                        day benefits and depend on the plan you choose.
(DEB), and get full cover for GP consultation fees.
Depending on the plan you choose, you also have
cover for two kids casualty visits, for each child
under the age of 10 years.
                                                                                                          21
DISCOVERY HEALTH MEDICAL SCHEME

     You also have additional benefits
     that enhance your cover
            International second                                                         Overseas treatment
            opinion services                                                             You have cover for treatment not available
            Through your specialist, you have access                                     in South Africa. The treatment must be
            to second opinion services from Cleveland                                    at a registered healthcare professional
            Clinic for life-threatening and life-changing                                and is paid up to a limit of R750 000 on
            conditions. We cover 100% on the Executive                                   the Executive Plan and R500 000 on the
            Plan and 50% on other plans for the cost                                     Comprehensive plans for each person.
            of the second opinion service.                                               If you are on the Executive Plan, you also
                                                                                         have cover up to R300 000 at a registered
            International travel                                                         healthcare provider for in-hospital
                                                                                         treatment that is available in South Africa.
            You have cover for emergency medical
            costs of up to US$1 million on the Executive                                 You will need to pay and claim back from
            Plan and R5 million on other plans for each                                  us when you return to South Africa.
            person on each journey while you travel                                      A co-payment of 20% applies. Only available
            outside of South Africa. This cover is for                                   on Executive and Comprehensive plans.
            a period of 90 days from your departure
            from South Africa. We may cover you at                                       Claims related to traumatic
            equivalent local costs for elective treatment
                                                                                         events
            received outside of South Africa, as long as
            the treatment is readily and freely available                                The Trauma Recovery Extender Benefit
            in South Africa and it would normally be                                     extends your cover for out-of-hospital
            covered by your plan according to the                                        claims related to certain traumatic events.
            Scheme Rules. Pre-existing conditions are                                    Claims are paid from the Trauma Recovery
            excluded. Not available on KeyCare plans.                                    Extender Benefit for the rest of the year in
                                                                                         which the trauma occurred, as well as the
            Africa evacuation cover                                                      year after the event occurred. You need to
                                                                                         apply for this benefit. The benefit does not
            You have cover for emergency medical
                                                                                         apply to Classic Zero MSA, Essential Smart,
            evacuations from certain sub-Saharan
                                                                                         Core and KeyCare Core plans.
            African countries back to South Africa.
            Pre-existing conditions are excluded.
            Not available on KeyCare plans.
22
     Visit www.discovery.co.za or click on find a provider in the Discovery app to find a provider.
Home-based care                                                        Frames and lenses
Discovery HomeCare is a unique home-                                   Your cover for eye care depends on the plan
based service that offers you quality                                  you choose. Enjoy savings of 20% for frames
care in the comfort of your own home                                   and lenses at an optometrist in the network.
when recommended by your doctor as                                     Your discount is immediate at the point
an alternative to a hospital stay when                                 of sale. Not available on KeyCare plans.
appropriate, with minimum disruption to
your normal routine and family life. Cover                             Additional benefits for allied,
includes postnatal care, end-of-life care,                             therapeutic, psychology services
IV infusions (drips) and wound care. These
                                                                       and external medical items
services are paid from the Hospital Benefit,
subject to approval. Discovery HomeCare                                You have access to unlimited, clinically
is the designated service provider (DSP)                               appropriate cover for biokineticists, acousticians,
for administration of defined intravenous                              physiotherapists or chiropractors, psychologists,
infusions. Avoid a 20% co-payment by using                             occupational therapists, speech and language
Discovery HomeCare for these infusions.                                therapists and external medical items,
                                                                       for a defined list of conditions.
Compassionate Care                                                     You need to apply for these benefits.
The CompassionateCare Benefit gives you                                Only available on Executive and
access to holistic home-based end-of-life                              Comprehensive plans.
care up to R44 050 on KeyCare plans and
R62 200 on all other plans for each person                             Non-invasive prenatal testing
in their lifetime.                                                     and newborn screening
Specialised medicine                                                   For expecting mothers who meet the
and technology                                                         Scheme’s clinical entry criteria, we will
                                                                       cover non-invasive prenatal screening
You have cover for a defined list of the                                from your available maternity benefits
latest treatments through the Specialised                              at the agreed rate.
Medicine and Technology Benefit, up to
R200 000 for each person each year.                                    You can also use your Medical Savings
                                                                       Account (MSA) for newborn screening to
A co-payment of up to 20% applies.                                     detect metabolic disorders. On the Smart,
Only available on Executive and                                        Core and KeyCare plans you need to pay
Comprehensive plans.                                                   for the tests.

                                                                                                                              23
                Discovery HomeCare is brought to you by Discovery Health (Pty) Ltd, registration number 1997/013480/07,
             an authorised financial services provider. Frames and lenses are brought to you by Discovery Health (Pty) Ltd,
                                            registration number 1997/013480/07, an authorised financial services provider.
04
DISCOVERY HEALTH MEDICAL SCHEME

Discovery Health Medical Scheme
plan range
                                                              Saver Series

01                                                            05
You can choose from 23 plans that are designed to meet your
                                                              Classic | Essential | Coastal
healthcare needs at every stage of your health journey.

                                                              Smart Series
  Executive Plan

02                                                            06
                                                              Classic | Essential

  Comprehensive Series                                        Core Series

03                                                            07
  Classic | Essential | Zero MSA                              Classic | Essential | Coastal

  Priority Series                                             KeyCare Series
  Classic | Essential                                         Plus | Core | Start
DISCOVERY HEALTH MEDICAL SCHEME

     Executive Plan
     Key benefits

Unlimited cover in any private                                                              Cover for comprehensive pre- and postnatal
hospital, including private ward cover                                                      healthcare services for maternity and early childhood

                                                                                                                 Additional cover through the
Guaranteed full cover                                                                                            Day-to-day Extender Benefit (DEB)
in hospital for specialists                                                                                      for GP consultation fees and kids
who we have a payment                                                                                            casualty visits when your Medical
arrangement with,                                                                                                Savings Account (MSA) runs out
and up to 300% of
the Discovery Health                                                                                             The highest savings account and
Rate (DHR) for other                                                                                             an unlimited Above Threshold
specialists                                                                                                      Benefit (ATB) for your day-to-day
                                                                                                                 healthcare needs

Full cover for chronic medicine                                                             The Global Treatment Platform gives you access to
on our formulary for all Chronic                                                            specialised, advanced medical care in South Africa
Disease List (CDL) conditions plus                                                          and abroad. Access to full cover for second opinion
some additional chronic conditions,                                                         services. Cover of up to US$1 million for medical

                                                                                                                                                            Executive
as well as access to an exclusive list                                                      emergencies when travelling outside of South Africa
of brand medicines

 itality is not part of Discovery Health Medical Scheme. Vitality is a separate wellness product, sold and administered by Discovery Vitality (Pty) Ltd,
V
registration number 1999/007736/07, an authorised financial services provider.                                                                                  Plan
25
EXECUTIVE PLAN

     Hospital cover
     We cover you in hospital for emergency
     and planned hospital admissions

There is no overall limit for your hospital cover. This is how we cover your hospital
account and accounts from your admitting doctor, anaesthetist or other approved
healthcare professionals (related accounts).

                                                       Hospital cover

                                                                Covered in full at the rate agreed with the hospital.
Hospital account
                                                                We cover up to R1 970 a day in a private ward.

                                                   Related accounts

Specialists we have a payment arrangement with                  Full cover

Specialists we don’t have a payment arrangement with            300% of the DHR

GPs and other healthcare professionals                          200% of the DHR

Radiology and pathology                                         100% of the DHR

MRI and CT scans                                                If related to your admission, we pay up to 100% of the DHR
                                                                from the Hospital Benefit. If not related to your admission,
                                                                or if for conservative back and neck treatment, we pay from
                                                                your day-to-day benefits.

Scopes                                                          We pay the hospital and related accounts from the Hospital
(gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy)       Benefit. If it is done in the doctor’s rooms, we pay the
                                                                account from your Hospital Benefit.

26
EXECUTIVE PLAN

Healthcare services with an annual limit

      Cochlear implants, auditory                                             Alcohol and drug rehabilitation
      brain implants and processors
                                                                              21 days for each person
      R223 700 for each person for each benefit
                                                                              Prosthetic devices used
      Internal nerve stimulators                                              in spinal surgery

      R153 600 for each person                                                There is no overall limit if you get your
                                                                              prosthesis from our preferred suppliers.
      Shoulder joint prostheses                                               If you choose not to, a limit of R25 500
                                                                              applies for the first level and R51 000
      There is no overall limit if you get your                               for two or more levels, limited to one
      prosthesis from our preferred suppliers.                                procedure for each person each year.
      If you choose not to, a limit of R41 700
      applies to each prosthesis.                                             Mental health

      Major joints surgery                                                    21 days for admissions or up to 15 out-
                                                                              of-hospital consultations for each person
      We cover planned hip and knee joint                                     for major affective disorders, anorexia
      replacements in full when you use                                       and bulimia and up to 12 out-of-hospital
      a provider in our network. If you go                                    consultations for acute stress disorder
      elsewhere, we will pay up to 80% of the                                 accompanied by recent significant trauma.
      Discovery Health Rate (DHR) for the
                                                                              21 days for all other mental health
      hospital account. A limit of R30 000 applies
                                                                              admissions.
      to each prosthesis for each admission.
      This network will not apply to emergency                                All mental health admissions are covered
      and trauma-related surgeries.                                           in full at a network facility. If you go
                                                                              elsewhere, we will pay up to 80% of the
                                                                              Discovery Health Rate (DHR) for the
                                                                              hospital account.

                                                                                                                                    27
                      Visit www.discovery.co.za or click on find a provider in the Discovery app to find providers in our network
EXECUTIVE PLAN

Cover for dental treatment in hospital

        Severe dental and oral surgery                          Dental limit
        The Severe Dental and Oral Surgery Benefit              There is no overall limit for basic dental
        covers a defined list of procedures, with               treatment. However, all dental appliances,
        no upfront payment and no overall limit.                their placement, and orthodontic treatment
        This benefit is subject to authorisation                (including related accounts for orthognathic
        and the Scheme’s rules.                                 surgery) are paid at 100% of the Discovery
                                                                Health Rate (DHR) and up to 300% of the DHR
        Other dental treatment in hospital                      for anaethetists. We pay these claims from
                                                                your day-to-day benefits, up to an annual
        You need to pay a portion of your hospital
                                                                limit of R27 300 a person. If you join the
        or day clinic account upfront for dental
                                                                Scheme after January, you won’t get the full
        admissions. This amount varies, depending
                                                                limit because it is calculated by counting the
        on your age and the place of treatment.
                                                                remaining months in the year.
        We pay the balance of the hospital account
        from your Hospital Benefit, up to 100% of
        the DHR. We pay the related accounts, which
        include the dentist and other related accounts,
        from your Hospital Benefit, up to 100%            Amount you need to pay upfront
        of the DHR. We pay specialists up to 300%         for dental treatment
        of the DHR.

        For members 13 years and older, we cover          Hospital
        routine conservative dentistry, such as
                                                                     Younger than 13          R2 400
        preventive treatment, simple fillings and
        root canal treatment, from your available                    13 and older             R6 200
        day-to-day benefits.
                                                          Day clinic

                                                                     Younger than 13          R1 100
                                                                     13 and older             R4 000

28
EXECUTIVE PLAN

   Maternity benefits
Cover for maternity and early childhood

These healthcare services for maternity and early childhood are covered from the Maternity Benefit at the
Discovery Health Rate. This cover does not affect your day-to-day benefits. Benefits will be activated once your
pregnancy profile is created in the Discovery app, on our website at www.discovery.co.za, when you preauthorise
your delivery or when you register your baby on the Scheme. These benefits are available per pregnancy per child,
up to two years after birth.

         Antenatal consultations                                      Pre- and postnatal care
         You are covered for up to 12 consultations                   You have cover for up to five pre-
         with your gynaecologist, GP or midwife.                      or postnatal classes or consultations,
                                                                      up until two years after birth, with a
         Ultrasound scans and prenatal                                registered nurse. You are also covered
         screening                                                    for one breastfeeding consultation with
                                                                      a registered nurse or breastfeeding
         You are covered for up to two 2D                             specialist.
         ultrasound scans, including one nuchal
         translucency test. 3D and 4D scans are
                                                                      Blood tests
         paid up to the rate we pay for 2D scans.
         You are also covered for one Non-Invasive                    You get cover for a defined basket
         Prenatal Test (NIPT) if you meet the clinical                of blood tests per pregnancy.
         entry criteria.
                                                                      GP and specialist care after birth
         Essential registered devices
                                                                      Your baby under the age of two years is
         You have cover of up to R5 000 for                           covered for two visits to a GP, paediatrician
         essential registered devices, for example                    or an ear, nose and throat specialist.
         breast pumps and smart thermometers.
         You are responsible for a 25% co-payment.
                                                                      Other healthcare services

         Private ward                                                 You are covered for one flu vaccination
                                                                      during your pregnancy. You also have
         You are covered for your delivery from                       access to postnatal care, which includes
         the Hospital Benefit. In addition, you have                  a postnatal consultation, a nutritional
         private ward cover up to R1 970 for your                     assessment with a dietitian and two
         approved hospital stay for the delivery.                     mental healthcare consultations with
                                                                      a counsellor or psychologist.
EXECUTIVE PLAN

   Day-to-day cover
    We cover your day-to-day healthcare expenses from your Medical Savings Account (MSA),
    Day-to-day Extender Benefit (DEB) or Above Threshold Benefit (ATB)

When you claim, we add up the following amounts to get to the Annual Threshold

Specialists we have a payment arrangement with                                Up to the agreed rate

Specialists we don’t have a payment arrangement with                          300% of the DHR

GPs and all other healthcare professionals                                    100% of the DHR

Preferred medicine                                                            100% of the DHR

Non-preferred medicine                                                        90% of the DHR

We also pay these amounts when you reach your Above Threshold Benefit (ATB). Over-the-counter medicine,
vaccines, immunisations and lifestyle-enhancing products do not add up to your Annual Threshold and are not
paid from your ATB. We add up the amount to the benefit limit available. If the claimed amount is less than the
Discovery Health Rate (DHR), we will pay and add the claimed amount to the Annual Threshold. Claims paid
from your Day-to-day Extender Benefit (DEB) will not accumulate to the Annual Threshold.

Some day-to-day healthcare services have limits. These are not separate benefits. Limits apply to claims paid
from your Medical Savings Account (MSA), DEB (where applicable), claims paid from your pocket and ATB.

Professional services                        Single member   One dependant        Two dependants      Three or more dependants

Allied, therapeutic and psychology
healthcare services*
(acousticians, biokineticists,
chiropractors, counsellors, dietitians,
homeopaths, nurses, occupational                  R23 300         R28 000                 R32 750              R39 300
therapists, physiotherapists, podiatrists,
psychologists, psychometrists, social
workers, speech and language therapists,
and audiologists)

Dental appliances and orthodontic                                       R27 300 for each person
treatment*

Antenatal classes                                                           R1 750 for your family
EXECUTIVE PLAN

Medicine                                        Single member           One dependant            Two dependants          Three or more dependants

Prescribed medicine*
                                                          R38 900               R45 600                 R52 200                       R58 900
(schedule 3 and above)

Over-the-counter medicine,                         We pay these claims from the available funds in your Medical Savings Account (MSA).
vaccines, immunisations and                        These claims do not add up to the Annual Threshold and are not paid from
lifestyle-enhancing products                       the Above Threshold Benefit (ATB).

Appliances and equipment

Optical*
(this limit covers lenses, frames, contact lenses and surgery or any healthcare service                            R8 000 for each person
to correct refractive errors of the eye)

External medical items* (like wheelchairs, crutches and prostheses)                                                R58 800 for your family

Hearing aids                                                                                                       R24 700 for your family

*
    If you join the Scheme after January, you won’t get the full limit because it is calculated by counting the remaining months in the year.

Contributions, MSA and
Annual Threshold amount

                                                                      Main member                        Adult                          Child*

Contributions                                                             R6 541                         R6 541                         R1 248

Annual Medical Savings Account amounts               **
                                                                         R19 620                        R19 620                         R3 744

Annual Threshold amounts           **
                                                                         R22 800                        R22 800                         R4 300

*	We count a maximum of three children when we calculate the monthly contributions, annual Medical Savings Account and Annual Threshold.
**	If you join the Scheme after January, you won’t get the full amount because it is calculated by counting the remaining months in the year.

                                                                                                                                                 31
DISCOVERY HEALTH MEDICAL SCHEME

     Comprehensive Series
     Key benefits

Unlimited private hospital cover                                                            Cover for comprehensive pre- and postnatal
                                                                                            healthcare services for maternity and early childhood

                                                                                                                 Additional cover through the Day-
                                                                                                                 to-day Extender Benefit (DEB) for
Guaranteed full cover
                                                                                                                 GP consultation fees and kids
in hospital for specialists
                                                                                                                 casualty visits when your Medical
who we have a payment
                                                                                                                 Savings Account (MSA) runs out
arrangement with, up to
200% of the Discovery                                                                                            A high savings account and
Health Rate (DHR) on                                                                                             an unlimited Above Threshold
Classic plans and up                                                                                             Benefit (ATB) for your day-to-day
to 100% of the DHR on                                                                                            healthcare needs
Essential plans for other
healthcare professionals                                                                                    Access to specialised, advanced medical
                                                                                                            care in South Africa and abroad

Full cover for chronic medicine on
                                                                                           Cover for medical emergencies
our formulary for all Chronic Disease
                                                                                           when travelling
List (CDL) conditions and if you use
MedXpress or a MedXpress network

                                                                                                                                                            Comprehensive
pharmacy on the Delta options.

 itality is not part of Discovery Health Medical Scheme. Vitality is a separate wellness product, sold and administered by Discovery Vitality (Pty) Ltd,
V
registration number 1999/007736/07, an authorised financial services provider.
                                                                                                                                                                   Series
32
COMPREHENSIVE SERIES

     The Comprehensive Series
     has five health plan options
     The five plan options have differences in benefits, as indicated below.
     All other benefits not mentioned in the table are the same across all plan options.

                                 Classic                Classic Delta               Essential             Essential Delta      Classic Zero MSA

                                                                    Hospital cover

Hospital network          Any private hospital     Private hospitals in      Any private hospital      Private hospitals in   Any private hospital
                                                   the Delta Network                                   the Delta Network

Cover for specialists,    200% of the Discovery Health Rate (DHR)            100% of the Discovery Health Rate (DHR)          200% of DHR
GPs and other
healthcare
professionals

MRI and CT scans          We pay the first R2 900 from your day-to-day benefits and the balance from your Hospital Benefit,   Covered at 100%
If not related to your    up to 100% of the Discovery Health Rate (DHR)                                                       of the DHR once you
admission or if for                                                                                                           reach your Annual
conservative back                                                                                                             Threshold
or neck treatment

                                                                Day-to-day benefits

Medical Savings           25% of your monthly contribution goes into         15% of your monthly contribution goes into       Not available
Account (MSA)             your Medical Savings Account (MSA)                 your Medical Savings Account (MSA)               on this plan

Day-to-day Extender        	
                            Face-to-face and video GP consultations          Face-to-face and video GP consultations          Not available
Benefit (DEB)              	
                            Kids casualty visits                                                                              on this plan

MRI and CT scans          We pay the first R2 900 from your day to-day benefits and the balance from your Hospital Benefit    Covered once you
                          (for conservative back and neck scans, specific rules apply)                                        reach your Annual
                                                                                                                              Threshold

Trauma Recovery           Extends your cover for out-of-hospital claims for recovery after certain traumatic events for the   Not available
Extender Benefit          rest of the year in which the trauma took place, and a year after the trauma                        on this plan

33
     Visit www.discovery.co.za or click on find a provider in the Discovery app to find providers in our network.
COMPREHENSIVE SERIES

   Hospital cover
   We cover you in hospital for emergency
   and planned hospital admissions

There is no overall limit for your hospital cover. This is how we cover your hospital
account and accounts from your admitting doctor, anaesthetist or other approved
healthcare professionals (related accounts).

                                                       Hospital cover

Hospital account                                                  Covered in full at the rate agreed with the hospital

On the Delta options, an upfront payment applies for admissions
                                                                  R7 650
to hospitals outside of the Delta Hospital Network

                                                     Related accounts

Specialists we have a payment arrangement with                    Full cover

Specialists we don’t have a payment arrangement                   Classic   | 200% of the Discovery Health Rate (DHR)
with and other healthcare professionals                           Essential | 100% of the Discovery Health Rate (DHR)

Radiology and pathology                                           100% of the Discovery Health Rate (DHR)

MRI and CT scans                                                  If related to your admission, we pay up to 100% of the
                                                                  Discovery Health Rate (DHR) from the Hospital Benefit.
                                                                  If not related to your admission or if for conservative back
                                                                  and neck treatment, we pay the first R2 900 of the scan
                                                                  from your day-to-day benefits and the balance of the scan
                                                                  from the Hospital Benefit, up to 100% of the DHR.
                                                                  On Classic Zero MSA, you are covered once you reach
                                                                  your Annual Threshold.

Scopes                                                            We pay the first R3 750 of the hospital account from your
(gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy)         day-to-day benefits and the balance of the hospital account
                                                                  and related accounts from the Hospital Benefit. If done in the
                                                                  doctor’s rooms, you won’t have to pay an amount upfront.
                                                                  We pay the account from the Hospital Benefit.

                                                                                                                                 34
COMPREHENSIVE SERIES

     Hospital cover
Healthcare services with an annual limit

             Cochlear implants, auditory                                                 Alcohol and drug rehabilitation
             brain implants and processors                                               21 days for each person
             R223 700 for each person for each benefit
                                                                                         Prosthetic devices used
             Internal nerve stimulators                                                  in spinal surgery
             R153 600 for each person                                                    There is no overall limit if you get your
                                                                                         prosthesis from our preferred suppliers.
             Shoulder joint prostheses                                                   If you choose not to, a limit of R25 500
                                                                                         applies for the first level and R51 000
             There is no overall limit if you get your
                                                                                         for two or more levels, limited to one
             prosthesis from our preferred suppliers.
                                                                                         procedure for each person each year.
             If you choose not to, a limit of R41 700
             applies to each prosthesis.
                                                                                         Mental health
             Major joints surgery                                                        21 days for admissions or up to 15 out-
                                                                                         of-hospital consultations for each person
             We cover planned hip and knee joint
                                                                                         for major affective disorders, anorexia
             replacements in full when you use
                                                                                         and bulimia and up to 12 out-of-hospital
             a provider in our network. If you go
                                                                                         consultations for acute stress disorder
             elsewhere, we will pay up to 80%
                                                                                         accompanied by recent significant trauma.
             of the Discovery Health Rate (DHR)
             for the hospital account. A limit of                                        21 days for all other mental health
             R30 000 applies to each prosthesis                                          admissions.
             for each admission. This network will
                                                                                         All mental health admissions are covered in
             not apply to emergency and trauma-
                                                                                         full at a network facility. If you go elsewhere,
             related surgeries.
                                                                                         we will pay up to 80% of the Discovery Health
                                                                                         Rate (DHR) for the hospital account.

35
     Visit www.discovery.co.za or click on find a provider in the Discovery app to find providers in our network.
COMPREHENSIVE SERIES

Cover for dental treatment in hospital

     Severe dental and oral surgery                         Dental limit
     The Severe Dental and Oral Surgery Benefit             There is no overall limit for basic dental
     covers a defined list of procedures, with              treatment. However, all dental appliances,
     no upfront payment and no overall limit.               their placement, and orthodontic treatment
     This benefit is subject to authorisation               (including related accounts for orthognathic
     and the Scheme’s rules.                                surgery) are paid at 100% of the Discovery
                                                            Health Rate (DHR) and up to 200% of the
     Other dental treatment in hospital                     DHR for anaethetists on Classic plans. We
                                                            pay these claims from your day-to-day
     You need to pay a portion of your hospital
                                                            benefits, up to an annual limit of R27 300
     or day clinic account upfront for dental
                                                            a person. If you join the Scheme after
     admissions. This amount varies, depending
                                                            January, you won’t get the full limit because
     on your age and the place of treatment.
                                                            it is calculated by counting the remaining
     We pay the balance of the hospital account             months in the year.
     from your Hospital Benefit, up to 100% of the
     DHR. We pay the related accounts, which
     include the dental surgeon’s account, from
     your Hospital Benefit, up to 100% of the        Amount you need to pay upfront
     Discovery Health Rate (DHR). On Classic
                                                     for dental treatment
     plans, we pay anaesthetists up to 200%
     of the DHR.
                                                     Hospital
     For members 13 years and older, we cover
     routine conservative dentistry, such as                    Younger than 13         R2 400
     preventive treatment, simple fillings and
                                                                13 and older            R6 200
     root canal treatment, from your available
     day-to-day benefits.                            Day clinic

                                                                Younger than 13         R1 100
                                                                13 and older            R4 000
COMPREHENSIVE SERIES

     Maternity benefits
Cover for maternity and early childhood

These healthcare services for maternity and early childhood are covered from the Maternity Benefit at the
Discovery Health Rate. This cover does not affect your day-to-day benefits. Benefits will be activated once your
pregnancy profile is created in the Discovery app, on our website at www.discovery.co.za, when you preauthorise
your delivery or when you register your baby on the Scheme. These benefits are available per pregnancy per child,
up to two years after birth.

         Antenatal consultations                                      Pre- and postnatal care
         You are covered for up to 12 consultations                   You have cover for up to five pre-
         with your gynaecologist, GP or midwife.                      or postnatal classes or consultations,
                                                                      up until two years after birth, with a
         Ultrasound scans and prenatal                                registered nurse. You are also covered
         screening                                                    for one breastfeeding consultation with a
                                                                      registered nurse or breastfeeding specialist.
         You are covered for up to two 2D ultrasound
         scans, including one nuchal translucency
                                                                      Essential registered devices
         test. 3D and 4D scans are paid up to the rate
         we pay for 2D scans. You are also covered                    You have cover of up to R5 000 for
         for one Non-Invasive Prenatal Test (NIPT)                    essential registered devices, for example
         if you meet the clinical entry criteria.                     breast pumps and smart thermometers.
                                                                      You are responsible for a 25% co-payment.
         Blood tests
                                                                      GP and specialist care after birth
         You get cover for a defined basket
         of blood tests per pregnancy.                                Your baby under the age of two years is
                                                                      covered for two visits to a GP, paediatrician
         Private ward                                                 or an ear, nose and throat specialist.

         You are covered for your delivery from
                                                                      Other healthcare services
         the Hospital Benefit. In addition, you have
         private ward cover up to R1 970 per                          You are covered for one flu vaccination
         day for your approved hospital stay                          during your pregnancy. You also have
         for the delivery.                                            access to postnatal care, which includes
                                                                      a postnatal consultation, a nutritional
37                                                                    assessment with a dietitian and two
                                                                      mental healthcare consultations with
                                                                      a counsellor or psychologist.
COMPREHENSIVE SERIES

   Day-to-day cover
    We cover your day-to-day healthcare expenses from your Medical Savings Account (MSA),
    Day-to-day Extender Benefit (DEB) or Above Threshold Benefit (ATB)

When you claim, we add up the following amounts to get to the Annual Threshold

Specialists we have a payment arrangement with                                                     Up to the agreed rate

Specialists we don’t have a payment arrangement with                                               100% of the DHR

GPs and all other healthcare services                                                              100% of the DHR

Preferred medicine                                                                                 100% of the DHR

Non-preferred medicine                                                                             75% of the DHR

We also pay these amounts when you reach your Above Threshold Benefit (ATB). Over-the-counter medicine,
vaccines, immunisations and lifestyle-enhancing products do not add up to your Annual Threshold and are
not paid from your ATB. We add up the amount to the benefit limit available. If the claimed amount is less than
the DHR, we will pay and add the claimed amount to the Annual Threshold. Claims paid from your Day-to-day
Extender Benefit (DEB) will not accumulate to the Annual Threshold.

Some day-to-day healthcare services have limits. These are not separate benefits. Limits apply to claims paid
from your MSA, DEB (where applicable), claims paid from your pocket and ATB.

Professional services                       Single member             One dependant            Two dependants           Three or more dependants

Allied, therapeutic and psychology healthcare services*
(acousticians, biokineticists, chiropractors, counsellors, dietitians, homeopaths, nurses, occupational therapists,
physiotherapists, podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists)

Classic                                             R18 600                  R25 250                   R30 800                    R35 700

Essential                                           R11 200                  R15 850                   R20 550                    R24 250

Dental appliances and orthodontic                                                  R27 300 for each person
treatment*

Antenatal classes                                                                   R1 750 for your family

* If you join the Scheme after January, you won’t get the full amount because it is calculated by counting the remaining months in the year.   38
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