Discovery Essential Priority medical aid plan: 2017

Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits) with limited above threshold benefit. 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, 100% scheme rate
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • If not related to admission or for conservative back or neck treatment: you pay the first R2,800 of the hospital account. Also, the first R2,750 of scan is 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:
  • Scopes: First R3,150 co-payment paid from day-to-day benefit
  • Conservative back and neck treatment, adenoidectomy, myringotomy (grommets), tonsillectomy: R2,800 co-payment
  • Arthroscopy, functional nasal procedures, hysterectomy, laparoscopy, hysteroscopy, endometrial ablation: R6,750 co-payment
  • Reflux surgery, spinal surgery, joint replacements: R13,850 co-payment
  • No co-payment is procedure can and is done out-of-hospital
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: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

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 benefits. Includes allied, therapeutic and psychology services
Main M1 M2 M3+
R6,250 R9,450 R11,750 R14,150

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MATERNITY BENEFITS:
Hospital stay:
  • Covered at 100% scheme rate for specialists
  • 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: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

Compare with these plans:

Consultations:
  • Paid from day-to-day benefit
  • 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 R200,000. Thereafter, a 20% co-payment applies
  • Unlimited palliative care cover for approved care at home

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: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

Compare with these plans:

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DENTISTRY:
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 R2,050 for admission to hospital, and R930 for admission to a day-clinic
    • If you are 13 and older, you pay R5,250 for admission to hospital, and R3,400 for admission to day-clinic
    • Balance of account is paid by scheme at 100% scheme rate
Out-of-hospital:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: from day-to-day benefit, limited to R15,750 per person. This limit includes claims for orthognathic surgery
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

Compare with these plans:

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

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

Compare with these plans:
Acute (presrcibed) medication:
  • Schedule 3 and above, from day-to-day benefit, up to the limits below
Main M1 M2 M3
R12,250 R14,500 R17,150 R20,850
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:
  • R4,200 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: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

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: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

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+
R6,250 R9,450 R11,750 R14,150

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OTHER BENEFITS:
General Appliances:
  • External appliances limited to R26,450 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: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

Compare with these plans:

1.1. Hearing Aids:
  • R13,000 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 R5 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: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
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: R2,551 R2,004 R1,012
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) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

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