DISCOVERY - HEALTH PLAN GUIDE 2019
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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 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 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 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
M
Ben
at
Ho
er
sp
ita
n
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
n
ty
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 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.
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 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.
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 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
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
t
ne
ne
efi
If your treatment costs more than the cover amount, we will cover up to On the Executive and Comprehensive plans you
Be
Be
en
80% of the subsequent additional costs, except if the treatment forms also have extended cover in full for a defined list of
yB
m
ion
mu
part of the extended cover offered on the Comprehensive and Executive
log
cancers and treatments that meet the Scheme’s
at
ini
ov
co
plans, which we will cover in full. criteria.
nn
dM
On
Oncology Benefit
yI
On Essential Smart we cover cancer treatment in our network.
be
ed
log
cri
nd
Oncology Innovation Benefit
co
All cancer-related healthcare services are covered up to 100% of the
es
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.
21DISCOVERY 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 | StartDISCOVERY 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
25EXECUTIVE 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.
26EXECUTIVE 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 networkEXECUTIVE 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
28EXECUTIVE 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 familyEXECUTIVE 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.
31DISCOVERY 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
32COMPREHENSIVE 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.
34COMPREHENSIVE 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 000COMPREHENSIVE 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. 38You can also read
