Discovery Essential Priority medical aid plan: 2019

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Essential Priority
2019 Costs:
Total Cost pm:

Main member:

R3,010

Adult:

R2,365

Child: (Pay only for first 3)

R1,202
Savings: R5,412 R4,248 R2,160
Self Payment Gap:
R10,468 R7,632 R3,040
Above Threshold: 17 9,550 4,600
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In brief (2018):
  • Scheme rate is 100%, and most day-to-day expenses are paid by scheme, or from savings, or from threshold benefit.
  • There is a self payment gap before threshold is reached. The threshold is limited.
  • There are co-payments for certain procedures
  • Discovery does pay for most maternity expenses and some preventative benefits such as mammograms and pap smears
  • You get unlimited cancer cover, with a co-payment after R200,000
  • Travel insurance and international treatment
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
See full benefits below

IN HOSPITAL PROCEDURES:
Essential Priority
Scheme Benefits: Notes and Links:
Specialists:
  • Up to 100% scheme rate
  • Contracted Specialists: covered in full
  • You or gap cover pay the balance, if any
Gap Cover
  • Gap cover is available for this plan. Budget about R350 for a fully comprehensive gap cover that will increase the scheme rate to 500% and pay most co-payments and increase sublimits.
Hospital Choice:
  • Choose any hospital
Specialised Radiology:
  • If not related to admission or for conservative back or neck treatment, R3,050 co-payment for the scan, and R2,750 towards the hospital account is paid by you.
Supplementary Services: (Physio, etc)
  • Covered in full for professionals with payment arrangement with Discovery
  • Otherwise, 100% scheme rate
Transplants:
  • Covered
Co-payments:
  • Defined procedures performed outside of day surgery network: R5,000
  • Scopes: R4,250 co-payment
  • Adenoidectomy, myringotomy (grommets), tonsillectomy, conservative back treatment: R3,350 co-payment
  • Arthroscopy, functional nasal procedures, hysterectomy, laparoscopy, hysteroscopy, endometrial ablation: R7,950 co-payment
  • Reflux surgery, spinal surgery, joint replacements: R16,350 co-payment
  • No co-payment if procedure can and is done out-of-hospital
  • In-hospital dentistry: co-payment required for some admissions. See dentistry benefit for details
Alternatives to hospitals:
  • Administration of IV, iron treatments, steroids and immunoglobulins when a hospital admission is not required: covered
  • Care for venous ulcers, diabetic foot ulcers, pressure sores and other moderate to severe wounds for patients who do not require hospital admission: covered
  • Terminal care: R62,200 per person, per lifetime
  • Cancer: Unlimited palliative care cover for approved care at home
Casualty:
  • Accident and trauma (emergency) related costs covered
Other:
  • Cochlear implants: R223,700
  • Internal Nerve stimulators: R153,600
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)
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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Essential Priority
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: R5,412 R4,248 R2,160
Self Payment Gap:
R10,468 R7,632 R3,040
Above Threshold: 17 9,550 4,600
General info:
GP consultations:
  • From day-to-day benefit unless PMB
Childcare:
Specialists consultations:
  • From day-to-day benefit, unless PMB
  • 100% scheme rate unless Discovery has payment arrangement with specialist
Pathology:
  • From day-to-day benefit, unless PMB
General radiology:
  • From day-to-day benefit, unless PMB
Specialised radiology:
  • From day-to-day benefit, unless PMB
Supplementary Services: (Physio, etc)
  • From day-to-day benefits. Includes allied, therapeutic and psychology services
Main M1 M2 M3+
R7,350 R11,100 R13,800 R16,650
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MATERNITY BENEFITS:
Essential Priority
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate
Consultations:
    Discovery pays for:
  • 8 consults, paid by scheme
  • Nuchal translucency or Non-Invasive Prenatal Test, paid by scheme
  • Certain blood tests, paid by scheme
  • Five pre- or postnatal classes with registered nurse
  • One lactation consult
Scans:
    Discovery pays for:
  • 2 x ultrasound scans
What next?
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CANCER (ONCOLOGY):
Essential Priority
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • Unlimited. After the first R200,000, a 20% co-payment applies for non-PMB cancers
  • All cancer-related treatments are covered at 100% scheme rate
  • Specialised medicine and technology: No benefit, unless PMB
  • Unlimited palliative care cover for approved care at home
What next?
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DENTISTRY:
Essential Priority
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit
Specialised Dentistry:
  • Specialised dentistry: from day-to-day benefit, limited to R16,300 per person
  • This limit includes claims for orthognathic surgery, dental appliances and their placements
In-Hospital Dentistry: In-hospital:
  • For severe dental and oral surgery, a defined list of procedures is included, with no upfront payment and no overall limit
  • Otherwise, you need to pay a portion of your account upfront:
    • If you are younger than 13, you pay R2,400 for admission to hospital, and R1,100 for admission to a day-clinic
    • If you are 13 and older, you pay R6,200 for admission to hospital, and R4,000 for admission to day-clinic
    • Balance of account is paid by scheme at 100% scheme rate
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above
What next?
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MEDICATION:
Essential Priority
Scheme Benefits: Notes and Links:
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary:
Acute (presrcibed) medication:
  • Schedule 3 and above, from day-to-day benefit, up to the limits below
Main M1 M2 M3
R14,400 R17,000 R20,200 R24,550
Over-the-counter:
  • From day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
Birth Control:
On Discharge:
  • See "Acute Medicine" benefit
Biological:
  • No benefit, unless PMB level of care
What next?
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OPTOMETRY:
Essential Priority
Scheme Benefits: Notes and Links:
Optometry:
Limit:R5,000 per person. Paid from day-to-day benefit.
Consult:from above limit
Frames:from above limit
Single lensesfrom above limit
Bifocals:from above limit
Multifocalsfrom above limit
Contactsfrom above limit
Refractive Surgery:from above limit
Notes:20% discount on frames and lenses at network optometrist
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MENTAL HEALTH:
Essential Priority
Scheme Benefits Notes and Links:
In-hospital:
  • Major affective disorders, anorexia and bulimia: 21 days for admissions or 15 out-of-hospital consultations
  • Acute stress disorder accompanied by recent significant trauma: 21 days for admissions or 12 out-of-hospital consultations
  • Other mental health admissions: 21 days in-hospital
  • Alcohol and drug rehab: 21 days in-hospital
  • All admissions are covered in full at a network facility, or at 80% scheme rate at a non-network facility
Out-of-hospital:
  • See above
  • Otherwise, paid from day-to-day benefit. Claims for psychologists and social workers fall into the supplementary benefit sub limit ie:
M M1 M2 M3+
R6,750 R10,200 R12,700 R15,300
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Trauma:
  • Offers out of hospital claims for recovery after traumatic events for rest of year, and year after that
What next?
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OTHER BENEFITS:
Essential Priority
Scheme Benefits Notes and Links:
General Appliances:
  • External appliances limited to R26,450 per family from day-to-day benefit
  • Cochlear implants: R214,500
  • No benefit
1.1. Hearing Aids:
  • R14,100 per family paid from day-to-day benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • Covered in full if you use network provider
HIV:
  • Covered if on the HIV Care program
Emergency Transport:
  • Discovery 911
International Insurance:
  • Up to R5 million per person on each journey for emergency medical costs while outside South Africa
  • Emergency medical evacuations from certain sub-Saharan African countries back to South Africa
Other:
  • Internal nerve stimulators: R153,600
  • DNA Analysis: paid in full from day-to-day benefit or 50% from above threshold
  • Second opinion from Cleveland Clinic for life-threatening and life-changing conditions. 50% co-payment
What next?
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WELLNESS/PREVENTATIVE BENEFITS:
Essential Priority
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered, for 65 yrs+
Pneumonia vaccines:
  • To be confirmed
Back Rehabilitation Programme: TBC
Biometric Screening:
  • Covered
Child Immunisation: TBC
Pap Smear:
  • Covered, every 3 years
Mammogram:
  • Covered, every 2 years
  • If you qualify, you can get Breast MRI and once-off BRCA test for breast screening
PAS Test:
  • Covered
HIV Test:
  • Covered
Other:
  • Kids' assessment, including height, weight, head circumference and health and milestone tracking
What next?
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PROSTHETICS:
Essential Priority
Scheme Benefits: Notes and Links:
Overal Limit:
  • Shoulder joint prostheses: no limit, unless you use non-network supplier, in which case R41,700 limit applies
  • Major joints surgery: no limit, unless you use non-network supplier, in which case 80% scheme rate and R30,000 per prosthesis limit applies
  • Spinal surgery: no limit, unless you use non-network supplier, in which case R25,500 limit for first level and R51,000 for two or more levels. Limted to one procedure per person per year.
Sub-limits: .
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.


    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised