Discovery Executive medical aid plan: 2017

Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB. Pay for maximum 3 children.

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
  • Covered in full for specialists with payment arrangement with Discovery
  • Otherwise, 300% scheme rate
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:
Hospital Choice:
  • Unlimited, with a R1,750 cover per day for private ward
Specialised Radiology:
  • Paid from day-to-day benefit
Supplementary Services: (Physio, etc)
  • Covered in full for professionals with payment arrangement with Discovery
  • Otherwise, 100% scheme rate
Transplants:
  • Covered
Co-payments: n/a
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
  • End of life care: R52,750 per person, per lifetime
  • Cancer: Unlimited palliative care cover for approved care at home

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • Paid from day-to-day benefit
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit
  • Limited to:
    M M1 M2 M3+
    R19,750 R23,750 R27,750 R33,350
  • For a defined list of conditions you get unlimited cover for biokineticists, acousticians, physiotherapists, occupational therapists, and speech and language therapists. Speak to Discovery directly

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MATERNITY BENEFITS:
Hospital stay:
  • Covered, including up to R1,750 per day for private ward
  • Three day visits with midwife if discharged a day early from hospital
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:

Consultations:
  • Paid from day-to-day benefit
  • If you are in the self payment gap, Discovery will cover consultations as long as you use an OB with whom scheme has payment arrangement
  • Antenatal classes: R1,550 per family from day-to-day benefit
Scans:
  • Paid from day-to-day benefit

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • First R400,000. Thereafter, a 20% co-payment applies
  • Unlimited palliative care cover for approved care at home
  • Specialised medicine and technology: R200,000 per person with a 20% co-payment

Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:

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DENTISTRY:
Dentistry:
    From day-to-day benefits, limited to R48,350 per person including all related accounts
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:

Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 23 conditions covered, up to a pre-set limit including an exclusive list of brand medicines.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:
Acute (presrcibed) medication:
  • Schedule 3 and above
  • Paid from day-to-day benefit, up to the limits below
Main M1 M2 M3+
R33,000 R38,700 R44,300 R49,950
Over-the-counter:
  • Paid 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
Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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OPTOMETRY:
Optometry:
  • R6,800 per person, including surgery to correct refractive errors, paid from day-to-day benefit
  • 20% discount on frames and lenses at a network optometrist
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • 21 days per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:


Out-of-hospital:
  • Major affective disorders, anorexia and bulimia: 15 consultations per person paid by scheme as an alternative to in-hospital treatment
  • Acute stress disorder due to recent significant trauma: 12 consultations per person paid by scheme as an alternative to in-hospital treatment
  • 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+
R19,750 R23,750 R27,750 R33,350

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OTHER BENEFITS:
General Appliances:
  • External appliances limited to R58,800 per family from day-to-day benefit
  • Cochlear implants: R207,000
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:

1.1. Hearing Aids:
  • R22,900 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 Coverage:
  • Up to R10 million per person on each journey for emergency medical costs while outside South Africa
  • Up to R500,000 for treatment overseas that is not available in South Africa, with a 20% co-payment
  • Emergency medical evacuations from certain sub-Saharan African countries back to South Africa
Other:
  • Internal nerve stimulators: R142,200
  • Trauma recovery: out-of-hospital claims related to certain traumatic events paid until the end of the year following the event
  • 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

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered, for 65yrs+
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Paid from day-to-day benefits
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

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

Compare with these plans:
Sub-limits:

    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