Discovery Health Medical Scheme Priority Plan Guide 2021

Priority
Plans 2021
Living my every moment
Classic | Essential
DISC O V E R Y H E ALT H ME DIC AL SC HEME
LIVE HEALTHY IN EVERY MOMENT

At Discovery Health Medical Scheme, we are reimagining healthcare so you can
experience quality care with advanced technology that supports you through
every life stage because we want you to live healthy in every moment.
Read this guide to understand more about your health plan including:
What to do when you need to go to a doctor or to a hospital
How you are covered for preventative screening, medical conditions, medicine and treatments
Which benefits you need to apply for and if there are any limits for certain benefits
Tips on how you can use technology to conveniently manage and access all the information you need through the Discovery app and website
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 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 our communication to you. The latest version of this guide as well as detailed benefit information is available on www.discovery.co.za.
2
CONTENTS
SCREENING AND
PREVENTATIVE
BENEFITS
KEY TERMS CONNECTED CARE
DAY-TO-DAY
KEY FEATURES
BENEFITS AND
AND BENEFITS
COVER
EMERGENCY COVER MATERNITY

AND PMBS BENEFITS
CHRONIC
CONDITIONS AND EXTRA BENEFITS
CARE PROGRAMMES
COVER FOR CANCER CONTRIBUTIONS
live healthy
IN EVERY MOMENT
HOSPITAL COVER
EXCLUSIONS
AND ANNUAL LIMITS
VALUE ADDED
DAY SURGERY
OFFERS
HO ME
KE Y TE RM S
Key
TERMS
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
About some of the terms we use in this document
S CRE E NI N G A ND
A C
PR E V EN TI O N
ABOVE THRESHOLD BENEFIT (ATB) CHRONIC DRUG AMOUNT (CDA)
CONNECTED CARE
Once the day-to-day claims you have sent to us add up to the Annual The Chronic Drug Amount (CDA) is the monthly amount that we pay up
Threshold, we pay the rest of your day-to-day claims from the Above to for a medicine class, subject to a member’s plan type. This applies
Threshold Benefit (ATB), at the Discovery Health Rate (DHR) or a portion to chronic medicine that is not listed on the formulary or medicine list. DAY-TO-DAY
of it. The Priority plans have a limited ATB. BENEFITS
AND COVER
CHRONIC ILLNESS BENEFIT (CIB)

ANNUAL THRESHOLD MATERNITY
BENEFITS
The Chronic Illness Benefit (CIB) covers you for a defined list of chronic
conditions. You need to apply to have your medicine and treatment covered CHRONIC
We set the Annual Threshold amount at the beginning of each year. CONDITIONS AND
The number and type of dependants (spouse, adult or child) on your for your chronic condition. CARE PROGRAMMES
plan will determine the amount.
The Annual Threshold is an amount that your claims need to add up to CO-PAYMENT CO V ER FOR
CANCE R
before we pay your day-to-day claims from the Above Threshold Benefit.
HO S PI TA L
This is an amount that you need to pay towards a healthcare service. The
C
CO VE R A N D
CHRONIC DISEASE LIST (CDL) amount can vary by the type of covered healthcare service, place of service A NNU A L L I M I TS
or if the amount the service provider charges is higher than the rate we
cover. If the co-payment amount is higher than the amount charged for the DAY SUR GE R Y
A defined list of chronic conditions we cover according to the Prescribed
healthcare service, you will have to pay for the cost of the healthcare service.
Minimum Benefits (PMBs).
COVER E X T RA B E NE F IT S
Cover refers to the benefits you have access to and how we pay for these C ON TRIB UT ION S
healthcare services such as consultations, medicine and hospitals, on your
health plan.
EX C LU SI O N S
4 GL O SSA RY 1/ 05
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE RM S
Key
TERMS
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
D D
PR E V EN TI O N
DAY-TO-DAY BENEFITS DESIGNATED SERVICE PROVIDER (DSP)
CONNECTED CARE
These are the available funds allocated to the Medical Savings Account (MSA) A healthcare provider (for example doctor, specialist, allied healthcare
and limited Above Threshold Benefit (ATB). professional, pharmacist or hospital) who we have an agreement with to
provide treatment or services at a contracted rate. Visit www.discovery.co.za DAY-TO-DAY
BENEFITS
or click on Find a healthcare provider on the Discovery app to view the full AND COVER
DAY-TO-DAY EXTENDER BENEFIT (DEB) list of DSPs.
MATERNITY
BENEFITS
Depending on your chosen plan, the Day-to-day Extender Benefit (DEB) DISCOVERY HEALTH RATE (DHR)
extends your day-to-day cover for essential healthcare services in our
CHRONIC
network if you have spent your annual Medical Savings Account (MSA) CONDITIONS AND
This is a rate we pay for healthcare services from hospitals, pharmacies, CARE PROGRAMMES
allocation and before you reach the Annual Threshold.
healthcare professionals and other providers of relevant health services.
CO V ER FOR
DEDUCTIBLE CANCE R
DISCOVERY HEALTH RATE FOR MEDICINE
HO S PI TA L
This is the amount that you must pay upfront to the hospital or day clinic for CO VE R A N D
This is the rate we pay for medicine. It is the Single Exit Price of medicine A NNU A L L I M I TS
specific treatments/procedures or if you use a facility outside of the network.
If the upfront amount is higher than the amount charged for the healthcare plus the relevant dispensing fee.
service, you will have to pay for the cost of the healthcare service. DAY SUR GE R Y
DISCOVERY HOME CARE
E X T RA B E NE F IT S
Discovery Home Care is an additional service that offers you quality
home-based care in the comfort of your home for healthcare services
like IV infusions, wound care, post-natal care and advanced illness care. C ON TRIB UT ION S
EX C LU SI O N S
Discovery Home Care is a service provider. Practice 080 000 8000190, Grove Nursing Services (Pty) Ltd registration number 2015/191080/07, trading
as Discovery HomeCare.
5 GL O SSA RY Find a healthcare provider is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services 2/ 05
provider and administrator of medical schemes. V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE RM S
Key
TERMS
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
D F
PR E V EN TI O N
DISCOVERY MEDXPRESS FIND A HEALTHCARE PROVIDER
CONNECTED CARE
Discovery MedXpress is a convenient and cost-effective medicine ordering Find a healthcare provider is a medical and provider search tool which
and delivery service for your monthly chronic medicine, or you can choose is available on the Discovery app or website www.discovery.co.za.
to collect your medicine in-store at a MedXpress Network Pharmacy. DAY-TO-DAY
BENEFITS
H HEALTHID AND COVER
E EMERGENCY MEDICAL CONDITION

HealthID is an online digital platform that gives your doctor fast, up-to-
MATERNITY
BENEFITS
An emergency medical condition, also referred to as an emergency, date access to your health information. Once you have given consent, your
doctor can use HealthID to access your medical history, make referrals to CHRONIC
is the sudden and, at the time, unexpected onset of a health condition CONDITIONS AND
that requires immediate medical and surgical treatment, where failure other healthcare professionals and check your relevant test results. CARE PROGRAMMES
to provide medical or surgical treatment would result in serious
M MEDICAL SAVINGS ACCOUNT (MSA)

impairment to bodily functions or serious dysfunction of a bodily CO V ER FOR
CANCE R
organ or part or would place the person’s life in serious jeopardy.
An emergency does not necessarily require a hospital admission. HO S PI TA L

The Medical Savings Account (MSA) is an amount that is allocated to you CO VE R A N D
We may ask you for additional information to confirm the emergency.
at the beginning of each year or when you join the Scheme. You pay this A NNU A L L I M I TS
amount back in equal portions as part of your monthly contribution. We pay

your day-to-day medical expenses such as GP and specialist consultations,
DAY SUR GE R Y
acute medicine, radiology and pathology from the available funds allocated
to your MSA. Any unused funds will carry over to the next year. Should you
leave the Scheme or change your plan partway through the year and have
used more of the funds than the amount you have contributed, you will E X T RA B E NE F IT S
need to pay the difference to us.
C ON TRIB UT ION S
Find a healthcare provider, Discovery MedXpress and Discovery HealthID are brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
EX C LU SI O N S
6 GL O SSA RY 3/ 05
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE RM S
Key
TERMS
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
M P
PR E V EN TI O N
MEDICINE LIST (FORMULARY) PAYMENT ARRANGEMENTS
CONNECTED CARE
A list of medicine we cover in full for the treatment of approved chronic The Scheme has payment arrangements with various healthcare
condition(s). This list is also known as a formulary. professionals and providers to ensure that you can get full cover
with no co-payments. DAY-TO-DAY
BENEFITS
N NETWORKS AND COVER
PREFERRED MEDICINE
MATERNITY
BENEFITS
Your health plan may require you to make use of specific hospitals, pharmacies,
doctors, specialists or allied healthcare professionals in a network. We have Preferred medicine includes preferentially priced generic and branded
payment arrangements with these providers to ensure you get access to medicines. CHRONIC
CONDITIONS AND
quality care at an affordable cost. By using network providers, you can CARE PROGRAMMES
avoid having to pay additional costs and co-payments yourself.
PREMIER PLUS GP
CO V ER FOR
CANCE R
Day Surgery Networks Doctor Networks
A Premier Plus GP is a network GP who has contracted with us to provide
HO S PI TA L
Full cover for a defined list You have full cover for GPs, you with coordinated care for defined chronic conditions. CO VE R A N D
of procedures in our Day specialists or allied healthcare A NNU A L L I M I TS
Surgery Network. professionals who we have

payment arrangements with.
DAY SUR GE R Y
Medicine Networks
Use MedXpress, or a MedXpress Network
Pharmacy to enjoy full cover and avoid
co-payments when claiming for chronic
C ON TRIB UT ION S
medicine on the medicine list.
EX C LU SI O N S
Discovery MedXpress is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
7 GL O SSA RY 4/ 05
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE RM S
Key
TERMS
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
P R
PR E V EN TI O N
PRESCRIBED MINIMUM BENEFITS (PMB) RELATED ACCOUNTS
CONNECTED CARE
In terms of the Medical Schemes Act of 1998 (Act No. 131 of 1998) and Any account other than the hospital account for in-hospital care.
its Regulations, all medical schemes have to cover the costs related to This could include the accounts for the admitting doctor, anaesthetist
the diagnosis, treatment and care of: and any approved healthcare expenses like radiology or pathology. DAY-TO-DAY
BENEFITS
AND COVER
An emergency medical condition
A defined list of 270 diagnoses

W WHO GLOBAL OUTBREAK BENEFIT
MATERNITY
BENEFITS
A defined list of 27 chronic conditions.
The WHO Global Outbreak Benefit provides cover for global disease
To access Prescribed Minimum Benefits (PMBs), there are rules defined CHRONIC
outbreaks recognised by the World Health Organization (WHO) such
by the Council for Medical Schemes (CMS) that apply: CONDITIONS AND
as COVID-19. This benefit offers cover for the vaccine, out-of-hospital CARE PROGRAMMES
Your medical condition must qualify for cover and be part management and appropriate supportive treatment.
of the defined list of Prescribed Minimum Benefit (PMB) conditions CO V ER FOR
CANCE R
The treatment needed must match the treatments
in the defined benefits
HO S PI TA L
CO VE R A N D
You must use designated service providers (DSPs) in our network. A NNU A L L I M I TS
This does not apply in emergencies. Where appropriate and according
to the Rules of the Scheme, you may be transferred to a hospital
DAY SUR GE R Y
or other service providers in our network, once your condition has
stabilised. If you do not use a DSP we will pay up to 80% of the Discovery
Health Rate (DHR). You will be responsible for the difference between
what we pay and the actual cost of your treatment.
If your treatment doesn’t meet the above criteria, we will pay

according to your plan benefits. C ON TRIB UT ION S
EX C LU SI O N S
8 GL O SSA RY 5/ 05
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Key
FEATURES
KE Y F E A TU RE S
A ND BE NE F I TS
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
PR E V EN TI O N
CONNECTED CARE
UNLIMITED COVER FOR FULL COVER FOR
HOSPITAL ADMISSIONS CHRONIC MEDICINES
DAY-TO-DAY
BENEFITS
AND COVER
There is no overall limit for hospital cover. You can go to Full cover for chronic medicine on our formulary
any private hospital. for all Chronic Disease List (CDL) conditions MATERNITY
BENEFITS
when you use MedXpress or a MedXpress
Network Pharmacy.
FULL COVER IN HOSPITAL CHRONIC
CONDITIONS AND
FOR SPECIALISTS CARE PROGRAMMES
SCREENING AND PREVENTION
CO V ER FOR
Full cover in hospital for specialists who we have CANCE R
a payment arrangement with, and up to 200% of Screening and prevention benefits that cover
the Discovery Health Rate (DHR) on Classic, and up vital tests to detect early warning signs of HO S PI TA L
CO VE R A N D
to 100% of the DHR on Essential for other healthcare serious illness. A NNU A L L I M I TS
professionals.
DAY SUR GE R Y
Vitality is a separate wellness product sold and administered by Discovery Vitality (Pty) Ltd, registration number 1999/007736/07. Limits, terms and conditions apply. C ON TRIB UT ION S
Discovery MedXpress is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
EX C LU SI O N S
9 KE Y F E A T U R E S 1/ 02
V A L U E -A DD ED
B EN E F IT S
Key
FEATURES
CONNECTED CARE EXTENSIVE COVER FOR PREGNANCY
You have access to care at home, including a Home You get comprehensive benefits for maternity and
Monitoring Device Benefit for essential home early childhood that cover certain healthcare services
monitoring, home-based care for follow-up treatment before and after birth.
after an admission and a Home Care Benefit for quality
care in the comfort of your own home.
COMPREHENSIVE
DAY-TO-DAY COVER
COVER WHEN TRAVELLING
We pay your day-to-day medical expenses from the

Cover for medical emergencies when travelling. available funds allocated to your Medical Savings Account
(MSA). The Day-to-day Extender Benefit (DEB) extends
your day-to-day cover for essential healthcare services
in our wellness network. You have a limited Above
Threshold Benefit (ATB) that gives you further day-to-day
cover once you have reached your Annual Threshold.
Discovery Home Care is a service provider. Practice 080 000 8000190, Grove Nursing Services (Pty) Ltd registration number 2015/191080/07, trading as
Discovery HomeCare.
Connected Care is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and
administrator of medical schemes.
10 KE Y F E A T U R E S
HO ME
KE Y TE R MS
THE BENEFITS
KE Y F E A TU RE S
on the different Priority plans

A ND BE NE F I TS
E ME RGE NCY
CO V ER AND PM B
The two plan options have differences in benefits, as shown in the table. All other
benefits not mentioned in the table are the same across both plan options.
S CRE E NI N G A ND
PR E V EN TI O N
Classic Essential
CONNECTED CARE
Day-to-day cover
Medical Savings 25% of your monthly contribution 15% of your monthly contribution DAY-TO-DAY
BENEFITS
Account (MSA) AND COVER
Day-to-day Extender The Day-to-day Extender Benefit (DEB) The Day-to-day Extender Benefit (DEB)
Benefit (DEB) extends your day-to-day cover for essential extends your day-to-day cover for essential MATERNITY
healthcare services in our wellness network. healthcare services BENEFITS
You also have additional cover for kids in our wellness network.
casualty visits. CHRONIC
CONDITIONS AND
CARE PROGRAMMES
Hospital cover
Cover for healthcare Twice the Discovery Health Rate (DHR) The Discovery Health Rate (DHR) (100%) CO V ER FOR
CANCE R
professionals in hospital (200%)
HO S PI TA L
CO VE R A N D
A NNU A L L I M I TS
DAY SUR GE R Y
C ON TRIB UT ION S
EX C LU SI O N S
11 KE Y F E A T U R E S 2/ 02
V A L U E -A DD ED
B EN E F IT S
HO ME
EMERGENCY
KE Y TE R MS
KE Y F E A T UR E S
Cover
A N D B EN EF I TS
EMERGENCY
C O V E R A ND P M B
What is a medical emergency?

DISC O VE RY H E ALT H ME DIC AL SC H E ME
S CRE E NI N G A ND
EMERGENCIES
PR E V EN TI O N
are covered in full. An emergency medical condition, CONNECTED CARE
also referred to as an emergency, WHAT WE PAY FOR

is the sudden and unexpected onset of a We pay for all of the following medical services DAY-TO-DAY
BENEFITS
health condition that requires immediate that you may receive in an emergency: AND COVER
If you have an emergency, medical and surgical treatment.

the ambulance (or other medical transport)
you can go straight to hospital. MATERNITY
BENEFITS
Failure to provide medical or surgical treatment the account from the hospital
If you need medically
would result in serious impairment to bodily the accounts from the doctor who admitted
equipped transport, functions or serious dysfunction of a bodily CHRONIC
you to the hospital CONDITIONS AND
like an ambulance, call organ or part or would place the person’s life CARE PROGRAMMES
the anaesthetist
our Emergency Assist. in serious jeopardy.
any other healthcare provider that
CO V ER FOR
An emergency does not necessarily require we approve. CANCE R
a hospital admission. We may ask you or your
0860 999 911

treating provider for additional information
HO S PI TA L
to confirm the emergency. CO VE R A N D
Click on Emergency Assist DAY SUR GE R Y

on your Discovery app
Assistance during or after a traumatic event
You have access to dedicated assistance in the event of a traumatic incident or after a traumatic event. E X T RA B E NE F IT S
By calling Emergency Assist you and your family have access to trauma support 24 hours a day. This service
also includes access to counseling and additional benefits for trauma related to gender-based violence.
C ON TRIB UT ION S
The Discovery app is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes. EX C LU SI O N S
12 E M E RGE N CI E S A ND P M B S 1/ 02
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
PMB KE Y F E A T UR E S
Prescribed Minimum Benefits

A N D B EN EF I TS
EMERGENCY
C O V E R A ND P M B
What are Prescribed Minimum Benefits?

S CRE E NI N G A ND
PR E V EN TI O N
Prescribed Minimum Benefit (PMB) conditions in terms of

CONNECTED CARE
the Medical Schemes Act 131 of 1998 and its Regulations,
all medical schemes have to cover the costs related to the
DAY-TO-DAY
diagnosis, treatment and care of: BENEFITS
AND COVER
An emergency medical condition
A defined list of 270 diagnoses MATERNITY
BENEFITS
A defined list of 27 chronic conditions.
CHRONIC
CONDITIONS AND
CARE PROGRAMMES
To access Prescribed Minimum Benefits (PMBs), there are rules defined by the
Council for Medical Schemes (CMS) that apply:
CO V ER FOR
Your medical condition must qualify for cover and be part of the defined list CANCE R
of Prescribed Minimum Benefit (PMB) conditions.

HO S PI TA L
The treatment needed must match the treatments in the defined benefits. CO VE R A N D
You must use designated service providers (DSPs) in our network. This does
not apply in emergencies. Where appropriate and according to the Rules of
the Scheme, you may be transferred to a hospital or other service providers DAY SUR GE R Y
in our network, once your condition has stabilised. If you do not use a DSP we
will pay up to 80% of the Discovery Health Rate (DHR). You will be responsible
for the difference between what we pay and the actual cost of your treatment. E X T RA B E NE F IT S
If your treatment doesn’t meet the above criteria, we will pay according to your
plan benefits.
C ON TRIB UT ION S
EX C LU SI O N S
13 E M E RGE N CI E S A ND P M B S 2/ 02
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
You have access to essential

SCREENING AND PREVENTION BENEFITS

KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
This benefit pays for certain tests that can detect early warning signs of serious illnesses. We cover various screening tests at our wellness providers, for example, blood glucose,
cholesterol, HIV, Pap smear or HPV test for cervical screening, mammograms and/or ultrasounds and prostate screenings, subject to the Scheme’s clinical entry criteria.
SC RE E NI NG A ND
P RE V E NTI O N
CONNECTED CARE
DAY-TO-DAY
BENEFITS
AND COVER
MATERNITY
BENEFITS
CHRONIC
CONDITIONS AND
CARE PROGRAMMES
CO V ER FOR
CANCE R
SCREENING FOR KIDS SCREENING FOR ADULTS SCREENING FOR SENIORS
HO S PI TA L
CO VE R A N D
This benefit covers growth assessment tests, This benefit covers certain tests such as blood glucose, In addition to the screening for adults, members aged A NNU A L L I M I TS
including height, weight, head circumference and blood pressure, cholesterol, body mass index and 65 years and older have cover for a group of age
health and milestone tracking at any one of our HIV screening at one of our wellness providers. We appropriate screening tests in our defined pharmacy
DAY SUR GE R Y
wellness providers. also cover a mammogram or ultrasound of the breast network. Cover includes hearing and visual screening
every two years, a Pap smear once every three years and a falls risk assessment. You may have cover for
or a HPV test once every 5 years, PSA test (prostate an additional GP consultation at a Premier Plus GP,
screening) each year and bowel cancer screening tests depending on your screening test results and if you
every two years for members between 45 and 75 years. meet the Scheme’s clinical entry criteria.
C ON TRIB UT ION S
EX C LU SI O N S
14 SCRE E N I N G A ND P R E V E NT I O N 1/ 02
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
We cover various screening WHAT WE PAY FOR
tests at our wellness

KE Y F E A T UR E S
providers. A N D B EN EF I TS
These tests are paid from the Screening and Prevention Benefit. Consultations that
do not form part of Prescribed Minimum Benefits (PMBs) will be paid from your
E ME RGE NCY
available day-to-day benefits. CO V ER AND PM B
ADDITIONAL TESTS SC RE E NI NG A ND
P RE V E NTI O N
Clinical entry criteria may apply to these tests: CONNECTED CARE

Defined diabetes and cholesterol screening tests
Breast MRI or mammogram and once-off BRCA testing for breast screening DAY-TO-DAY
BENEFITS
Colonoscopy for bowel cancer screening AND COVER
Pap smear or HPV test for cervical screening.

MATERNITY
Seasonal flu vaccine for members who are: BENEFITS
Pregnant
65 years or older CHRONIC
CONDITIONS AND
Registered for certain chronic conditions CARE PROGRAMMES
Healthcare professionals.
CO V ER FOR
Visit www.discovery.co.za to view the detailed Screening and Prevention Benefit guide. CANCE R
HO S PI TA L
CO VE R A N D
DAY SUR GE R Y
C ON TRIB UT ION S
EX C LU SI O N S
15 SCRE E N I N G A ND P R E V E NT I O N 2/ 02
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
CONNECTED
KE Y F E A T UR E S
CARE
A N D B EN EF I TS
E ME RGE NCY
Access quality
CO V ER AND PM B
HEALTH MONITORING MEDICINE ORDERING

healthcare DEVICES AND TRACKING
S CRE E NI N G A ND
PR E V EN TI O N
from home CONNECTED CARE

Access to the latest medical Order and track your medicine
examination and remote monitoring delivery from dispensary to
and point-of-care devices to enable your door DAY-TO-DAY
quality care from home BENEFITS
AND COVER
Discovery Health Medical
Scheme gives you access to
MATERNITY
health and wellness services BENEFITS
from the comfort of your

ONLINE
home. Connected Care is ELECTRONIC COACHES
CHRONIC
CONDITIONS AND
an integrated healthcare PRESCRIPTIONS CARE PROGRAMMES
ecosystem of benefits,
services and connected Personalised coaching
CO V ER FOR
CANCE R
digital capabilities to help Seamless e-scripting to give you consultations to help you better
quicker access to your medicine manage your chronic conditions
you manage your health HO S PI TA L
from home CO VE R A N D
and wellness at home. A NNU A L L I M I TS
DAY SUR GE R Y
HOME
NURSES CONDITION-SPECIFIC E X T RA B E NE F IT S
INFORMATION
Visit www.discovery.co.za to view the Hospital-related care with home C ON TRIB UT ION S
detailed Connected Care Benefit guide. nurses to care for you at home Educational content specific to
your condition, at your fingertips
EX C LU SI O N S
Connected Care is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
16 CO N N E CT E D C A R E 1/ 03
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Introducing your access to

CONNECTED CARE
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
Access to quality care from home
S CRE E NI N G A ND
PR E V EN TI O N
Through advanced digital technology and smart health and point-of-care devices, Connected Care enables you and your doctor to access and deliver healthcare whenever
you need it from the comfort of your home.
CONNECTED CARE
DAY-TO-DAY
BENEFITS
AND COVER
MATERNITY
BENEFITS
CHRONIC
CONDITIONS AND
CARE PROGRAMMES
CO V ER FOR
CANCE R
CONNECTED CARE FOR MEMBERS CONNECTED CARE FOR ACUTE CARE CONNECTED CARE FOR MEMBERS
AT HOME AT HOME WITH CHRONIC CONDITIONS HO S PI TA L
CO VE R A N D
You can connect to doctors through virtual consultations For members who qualify, you have access to You and your doctor can manage your chronic
DAY SUR GE R Y
like never before, from the comfort of your home. hospital-level care in your home instead of having to condition through Connected Care in the comfort
go to hospital for acute hospital care. This includes of your home. You have access to a range of digital
The Home Monitoring Device Benefit gives you
follow-up care once discharged. services linked to smart remote monitoring and
access to a range of essential and registered home E X T RA B E NE F IT S
point-of-care devices and personalised coaching
monitoring devices for certain chronic and acute
consultations, for qualifying members, to help you
conditions. Approved cover for these devices will not
track and manage your chronic condition from home.
affect your day-to-day benefits. C ON TRIB UT ION S
EX C LU SI O N S
Connected Care is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Your benefits through

CONNECTED CARE
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
You have access to a Home Home-based care for follow-up
Monitoring Device Benefit treatment after an admission S CRE E NI N G A ND
for essential home monitoring PR E V EN TI O N
Clinically appropriate conditions such as chronic

If you meet the Scheme’s clinical entry criteria, you obstructive pulmonary disease, chronic cardiac
failure, ischaemic heart disease and pneumonia CONNECTED CARE
have healthcare cover up to a limit of R4 000 per
person per year, at 100% of the Discovery Health Rate have access to enhanced home-based care once
(DHR), for the monitoring of defined conditions such discharged from hospital. If you meet the clinical DAY-TO-DAY
as chronic obstructive pulmonary disease, congestive entry criteria you have cover for bedside medicine BENEFITS
AND COVER
cardiac failure, diabetes, pneumonia and COVID-19. reconciliation prior to admission discharge, a follow-
up consultation with a GP or specialist, and a defined
The Scheme also covers defined point of care medical basket of supportive care at home that includes a
MATERNITY
BENEFITS
devices up to 75% of the Discovery Health Rate (DHR), face-to-face consultation and virtual consultations
if you meet the clinical entry criteria. You will need to with a Discovery Home Care nurse.
CHRONIC
pay 25% towards the cost of these devices. CONDITIONS AND
CARE PROGRAMMES
You have access to the latest remote monitoring medical Home care benefit
examination device called TytoHome. TytoHome allows
CO V ER FOR
you to conduct a medical examination, sending throat Discovery Home Care is a service that offers you CANCE R
and ear images and heart and lung sounds in real-time quality care in the comfort of your own home when
to your doctor. recommended by your doctor as an alternative to a
HO S PI TA L
hospital stay. Services include postnatal care, end-of- CO VE R A N D
life care, IV infusions (drips) and wound care. These
services are paid from the Hospital Benefit, subject
to approval. Discovery Home Care is the Designated DAY SUR GE R Y
Service Provider (DSP) for administration of defined

intravenous infusions. Avoid a 20% co-payment by
using Discovery Home Care for these infusions. E X T RA B E NE F IT S
C ON TRIB UT ION S
Discovery Home Care is a service provider. Practice 080 000 8000190, Grove Nursing Services (Pty) Ltd registration number 2015/191080/07,
trading as Discovery HomeCare.
Connected Care is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider
EX C LU SI O N S
and administrator of medical schemes.
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Day-to-day
BENEFITS
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
We cover your day-to-day healthcare expenses from your
Medical Savings Account (MSA), Day-to-day Extender S CRE E NI N G A ND
Benefit (DEB) or Above Threshold Benefit (ATB). PR E V EN TI O N
The Medical Savings Account Day-to-day Extender Benefit The Above Threshold Benefit CONNECTED CARE
(MSA) (DEB) (ATB)

DAY-TO-DAY
BENEFITS
We pay your day-to-day medical expenses such as Pays for certain day-to-day benefits after you have The Above Threshold Benefit starts paying for day-to- AND COVER
GP and specialist consultations, medicine (excluding run out of money in your MSA and before you reach day expenses once you reach your Annual Threshold.
registered chronic medicine), radiology and the Annual Threshold. Covers video call consultations MATERNITY
pathology from your available funds allocated to your with a network GP as well as unlimited pharmacy clinic
WHAT WE PAY FOR BENEFITS
MSA. Any amount that is left over will carry over to consultations in our defined wellness network. You also The Above Threshold Benefit (ATB) is limited and
the next year. have unlimited cover for consultations with a network covers all day-to-day expenses at the Discovery CHRONIC
CONDITIONS AND
GP, when referred by the pharmacy clinic virtual GP. Health Rate (DHR) or at a portion of it. Certain CARE PROGRAMMES
We cover consultations up to the Discovery Health Rate benefit limits may apply. You will need to pay for any
(DHR). On the Classic plan, kids younger than 10 years difference between the Discovery Health Rate (DHR) CO V ER FOR
have access to two kids casualty visits a year. and the amount claimed, as well as any amount CANCE R
which exceeds the annual benefit limit (where

applicable). HO S PI TA L
The Self-payment Gap (SPG) CO VE R A N D
Some claims do not add up to your Annual A NNU A L L I M I TS
If your MSA runs out before you reach your Annual Threshold, you will have to pay for claims from your own pocket Threshold or pay from the ATB for example:
until your claims reach the Annual Threshold amount. This period is known as the Self-Payment Gap (SPG). DAY SUR GE R Y
Medicine that you do not need a prescription
It is important that you continue to send your claims during the SPG so that we know when you reach your Annual for (over-the-counter medicine)
Threshold for claims. Vaccines and immunisations
Lifestyle-enhancing products
Claims paid in excess of the Discovery Health
Rate (DHR). C ON TRIB UT ION S
For more detail on how you are covered visit

Do we cover on our website www.discovery.co.za
EX C LU SI O N S
19 DA Y -T O -DA Y B E N E F I T S 1/ 03
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Day-to-day We cover your day-to-day healthcare expenses from your

Medical Savings Account (MSA), Day-to-day Extender Benefit
COVER
KE Y F E A T UR E S
A N D B EN EF I TS
(DEB) and limited Above Threshold Benefit (ATB).
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
We add these amounts to the Annual The tables below show how much we pay for your day-to-day healthcare expenses on the Priority plans. PR E V EN TI O N
Threshold and pay these amounts
When you claim, we add up the following amounts to get to the Annual Threshold.
when you reach your limited Above
Threshold Benefit (ATB). We add CONNECTED CARE
Healthcare providers and medicine What we pay
up the amount to the benefit limit
available. If the claimed amount Specialists we have an arrangement with Up to the rate we have agreed with the specialist
DAY-TO-DAY
is less than the Discovery Health BENEFITS
Rate (DHR), we will pay and add Specialists we do not have an arrangement with The Discovery Health Rate (DHR) (100%) AND COVER
the claimed amount to the Annual GPs and other healthcare professionals The Discovery Health Rate (DHR) (100%)
Threshold. Claims paid from your MATERNITY
Preferred medicine The Discovery Health Rate (DHR) (100%) BENEFITS
Day-to-day Extender Benefit (DEB)
will not accumulate to the Annual Non-preferred medicine Up to 75% of the Discovery Health Rate (DHR) if the price of the
medicine is within 25% of the preferred equivalent, or up to 50% CHRONIC
Threshold. CONDITIONS AND
of the DHR if the price of the medicine is more than 50% of the CARE PROGRAMMES
Some day-to-day healthcare services price of the preferred equivalent
have limits. These are not separate
CO V ER FOR
benefits. Limits apply to claims CANCE R
paid from your MSA, claims paid by Professional Single One Two Three or more
you and paid from the ATB. We pay services member dependant dependants dependants
HO S PI TA L
day-to-day benefits up to the ATB Allied, therapeutic and psychology healthcare services*
CO VE R A N D
limit or up to the limit that applies, (acousticians, biokineticists, chiropractors, counsellors, dietitians, homeopaths, nurses, occupational therapists, physiotherapists,
depending on the one you reach podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists)
first. DAY SUR GE R Y
Classic R12 500 R17 700 R22 900 R27 050
Essential R8 300 R12 500 R15 550 R18 750

Dental appliances and orthodontic treatment* R19 150 per person
Antenatal classes R1 960 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. C ON TRIB UT ION S
EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Three or more
Medicine Single member One dependant Two dependants
dependants
KE Y F E A T UR E S
A N D B EN EF I TS
Prescribed medicine* (schedule 3 and above)
Classic R22 850 R27 700 R33 350 R36 400

E ME RGE NCY
CO V ER AND PM B
Essential R16 200 R19 150 R22 750 R27 650
Over-the-counter medicine, vaccines, immunisations and We pay these claims from the available funds in your Medical Savings Account (MSA). These claims do not add up to the
S CRE E NI N G A ND
lifestyle-enhancing products Annual Threshold and are not paid from the Above Threshold Benefit (ATB). PR E V EN TI O N
Appliances and equipment CONNECTED CARE
Optical*
(this limit covers lenses, frames, contact lenses and surgery or any healthcare service to correct R5 610 per person DAY-TO-DAY
refractive errors of the eye) BENEFITS
AND COVER
External medical items* Classic R40 550 for your family
(like wheelchairs, crutches and prostheses)
MATERNITY
Essential R27 250 for your family BENEFITS
Hearing aids Classic R21 350 for your family CHRONIC

CONDITIONS AND
CARE PROGRAMMES
Essential R15 200 for your family
CO V ER FOR
*
If you join the Scheme after January, you will not get the full limit because it is calculated by counting the remaining months in the year. CANCE R
HO S PI TA L
CO VE R A N D
DAY SUR GE R Y
C ON TRIB UT ION S
EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
You have cover for During pregnancy After you give birth
MATERNITY
KE Y F E A T UR E S
ANTENATAL CONSULTATIONS GP AND SPECIALISTS TO HELP YOU A N D B EN EF I TS
AFTER BIRTH
We pay for up to eight consultations with your
gynaecologist, GP or midwife. Your baby under the age of two years is
and early childhood
E ME RGE NCY
covered for two visits to a GP, paediatrician CO V ER AND PM B
ULTRASOUND SCANS AND SCREENINGS or an ear, nose and throat specialist.

DURING PREGNANCY
S CRE E NI N G A ND
OTHER HEALTHCARE SERVICES PR E V EN TI O N
You are covered for up to two 2D ultrasound
scans, including one nuchal translucency test. You also have access to postnatal care,
You get cover for healthcare services related 3D and 4D scans are paid up to the rate we which includes a postnatal consultation for CONNECTED CARE
to your pregnancy and treatment for the first pay for 2D scans. You are also covered for one complications post delivery, a nutritional
two years of your baby’s life. This applies from chromosome test or Non-Invasive Prenatal Test assessment with a dietitian and two mental
(NIPT) if you meet the clinical entry criteria. healthcare consultations with a counsellor DAY-TO-DAY
the date of activation of the benefit for each BENEFITS
or psychologist. AND COVER
pregnancy and for each child from birth
FLU VACCINATIONS
until they are two years old.
MATERNITY
We pay for one flu vaccination during BENEFITS
your pregnancy.
HOW TO GET THE BENEFIT
CHRONIC
BLOOD TESTS CONDITIONS AND
CARE PROGRAMMES
We pay for a defined list of blood tests
You can activate the benefit in any of these ways: for each pregnancy.
CO V ER FOR
Create your pregnancy profile in the Discovery app CANCE R
or on our website at www.discovery.co.za

HO S PI TA L
When you register your baby as a dependant on CO VE R A N D
the Scheme. A NNU A L L I M I TS
PRE- AND POSTNATAL CARE
DAY SUR GE R Y
We pay for a maximum of five antenatal or postnatal classes or consultations with a registered nurse up
until two years after you have given birth. We pay for one breastfeeding consultation with a registered
The Discovery app is brought to you by Discovery Health (Pty) nurse or a breastfeeding specialist.
Ltd; registration number 1997/013480/07, an authorised financial
services provider and administrator of medical schemes. Visit www.discovery.co.za to view the detailed Maternity Benefit guide.
C ON TRIB UT ION S
EX C LU SI O N S
22 MA T E RN I T Y B E N E F I T S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
CHRONIC What we cover

KE Y F E A T UR E S
You have access to treatment for a list of medical conditions under
benefits
A N D B EN EF I TS
the Prescribed Minimum Benefits (PMBs). The PMBs cover the
27 chronic conditions on the Chronic Disease List (CDL).
E ME RGE NCY
Our plans offer benefits that are richer than PMBs. To access CO V ER AND PM B
PMBs, certain rules apply.
You have cover for treatment for ongoing MEDICINE COVER FOR THE CHRONIC DISEASE LIST S CRE E NI N G A ND
PR E V EN TI O N
medical conditions (chronic conditions). You have full cover for approved chronic medicine on our medicine
You have cover for the 27 medical list. For medicine not on our list, we cover you up to a set monthly
CONNECTED CARE
rand amount called the Chronic Drug Amount (CDA).
conditions set out in the list of chronic
conditions (CDL). HOW WE PAY FOR MEDICINE DAY-TO-DAY
BENEFITS
We pay for medicine up to a maximum of the Discovery Health AND COVER
Rate (DHR). The DHR for medicine is the price of the medicine
and the fee for dispensing it. MATERNITY
BENEFITS
CHRONIC
CONDITIONS AND
CARE PROGRAMMES
How to get the benefit
CO V ER FOR
You must apply for the Chronic Illness Benefit (CIB). CANCE R
Your doctor must complete the form online or send

it to us for approval. HO S PI TA L
CO VE R A N D
Visit www.discovery.co.za to view the detailed Chronic Illness A NNU A L L I M I TS
Benefit (CIB) guide.
DAY SUR GE R Y
C ON TRIB UT ION S
EX C LU SI O N S
23 CH RO N I C B E NE F I T S 1/ 03
V A L U E -A DD ED
B EN E F IT S
HO ME
CHRONIC
KE Y TE R MS
You have cover for treatment for ongoing medical conditions (chronic conditions).
You have cover for the 27 medical conditions set out in the list of chronic conditions KE Y F E A T UR E S
benefits
A N D B EN EF I TS
(CDL).
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
PR E V EN TI O N
CHRONIC DISEASE LIST (CDL) CONDITIONS

DISC O VE RY HE ALTH ME DIC AL SC H E ME
CONNECTED CARE
Chronic conditions covered on all plans If you need chronic dialysis

DAY-TO-DAY
We cover these expenses in full if we have approved your treatment plan and BENEFITS
you use a provider in our network. If you go elsewhere, we will pay up to 80% AND COVER
A Addison’s disease, asthma of the Discovery Health Rate (DHR).

MATERNITY
BENEFITS
B Bipolar mood disorder, bronchiectasis
C Cardiac failure, cardiomyopathy, chronic obstructive pulmonary disease, CHRONIC

CONDITIONS AND
chronic renal disease, coronary artery disease, Crohn’s disease CARE PROGRAMMES
D Diabetes insipidus, diabetes Type 1, diabetes Type 2, dysrhythmia CO V ER FOR

CANCE R
E Epilepsy
HO S PI TA L
G Glaucoma CO VE R A N D
H Haemophilia, HIV, hyperlipidaemia, hypertension, hypothyroidism

DAY SUR GE R Y
M Multiple sclerosis
P Parkinson’s disease E X T RA B E NE F IT S
R Rheumatoid arthritis
C ON TRIB UT ION S
S Schizophrenia, systemic lupus erythematosus
U Ulcerative colitis
EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Where to get your chronic MedXpress and MedXpress

Network Pharmacies
MEDICINE
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
Use a pharmacy in our networks

S CRE E NI N G A ND
Avoid a 20% co-payment on your chronic medicine by using our Designated Service Providers (DSPs), PR E V EN TI O N
MedXpress and MedXpress Network Pharmacies.
MedXpress and MedXpress network pharmacies CONNECTED CARE
You can order or reorder your medicine online through MedXpress and have it delivered DAY-TO-DAY
BENEFITS
to your work or home AND COVER
or
Order your medicine online and collect instore at a MedXpress Network Pharmacy MATERNITY
BENEFITS
or
Fill a prescription as usual at any MedXpress Network Pharmacy.
CHRONIC
CONDITIONS AND
CARE PROGRAMMES
Medicine tracker
CO V ER FOR
You can set up reminders and prompts to assist you with taking your medicine on time and CANCE R
as prescribed. Your approved chronic medicines will automatically be displayed, and you will
then be prompted to take your medicine and confirm when each dose is taken. HO S PI TA L
CO VE R A N D
DAY SUR GE R Y
HOW TO ORDER E X T RA B E NE F IT S
Discovery app or
View all pharmacy network providers using www.discovery.co.za
C ON TRIB UT ION S
Find a healthcare provider on the Discovery app
Find a healthcare provider, the Discovery app, MedXpress and Medicine tracker are brought to you by Discovery Health (Pty) Ltd; registration number
1997/013480/07, an authorised financial services provider and administrator of medical schemes. EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
CARE
KE Y F E A T UR E S
programmes
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
Condition-specific care programmes for diabetes, mental health, HIV and
heart conditions.
S CRE E NI N G A ND
PR E V EN TI O N
We cover condition-specific care programmes that help you to manage diabetes, mental health, HIV or heart-
related medical conditions. You have to be registered on these condition-specific care programmes to unlock CONNECTED CARE
additional benefits and services. You and your Premier Plus GP can track progress on a personalised dashboard
to identify the next steps to optimally manage your condition and stay healthy over time.
DAY-TO-DAY
BENEFITS
AND COVER
MENTAL HEALTH CARE PROGRAMME
MATERNITY
BENEFITS
Once enrolled on the programme by your network psychologist or Premier Plus GP, you have access to defined cover
for the management of major depression. Enrolment on the programme unlocks cover for prescribed medicine, CHRONIC
CONDITIONS AND
access to either individual or group psychotherapy sessions (virtual and face-to-face therapy) and additional GP CARE PROGRAMMES
consultations to allow for effective evaluation, tracking and monitoring of treatment. Qualifying members will also have
access to a relapse prevention programme, which includes additional cover for a defined basket of care for psychiatry CO V ER FOR
consultations, counseling sessions and care coordination services. CANCE R
HO S PI TA L
CARDIO CARE PROGRAMME CO VE R A N D
If you are registered on the Chronic Illness Benefit (CIB) for hypertension, hyperlipidaemia or ischaemic heart DAY SUR GE R Y
disease, you have access to a defined basket of care and an annual cardiovascular assessment, if referred by your
nominated Premier Plus GP and enrolled on the Cardio Care programme. If you are also registered for diabetes
you need to see your nominated Premier Plus GP to avoid a 20% co-payment. E X T RA B E NE F IT S
C ON TRIB UT ION S
EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
CARE Track your Health

KE Y F E A T UR E S
You can get personalised health goals that help you
programmes
A N D B EN EF I TS
to manage your weight, nutrition and exercise. If
you are at risk of developing or you are diagnosed
with cardiovascular disease or diabetes, we will give E ME RGE NCY
CO V ER AND PM B
you goals tailored to your circumstances. You can
track your progress on the Discovery app and we will
reward you for meeting your goals. S CRE E NI N G A ND
PR E V EN TI O N
E CON CONNECTED CARE

CAR SUL
DIABETES CARE PROGRAMME E CT
ED TP
RE
N N M
CO IE
R
P DAY-TO-DAY
BENEFITS
LU
AND COVER
S
If you are registered on the Chronic Illness Benefit (CIB) for diabetes, your nominated Premier Plus
GP
GP can enrol you on the Diabetes Care programme. The programme unlocks cover for additional
MATERNITY
glucometer strips and consultations with dietitians and biokineticists. You may also have access to
CH
BENEFITS
COA
a nurse educator to help you with the day-to-day management of your condition. You have to see
your nominated Premier Plus GP to avoid a 20% co-payment.
H E ALT H
CHRONIC
CONDITIONS AND
DIETITIAN
CARE PROGRAMMES
HIV CARE PROGRAMME
CO V ER FOR
CANCE R
If you are registered on the HIV programme, you are covered for the care you need, which
includes additional cover for social workers. You can be assured of confidentiality at all times. HO S PI TA L
CO VE R A N D
You have to see a Premier Plus GP to avoid a 20% co-payment. You need to get your medicine
TR
AC
from a Designated Service Provider (DSP) to avoid a 20% co-payment.
K
YO
I
ST
R IC
U
HE
AL ET DAY SUR GE R Y
TH I N
OK
BI
Connected Care is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised
financial services provider and administrator of medical schemes. Click on Track your Health
Track your health and the Discovery app are brought to you by Discovery Health (Pty) Ltd; registration number on the Discovery app to C ON TRIB UT ION S
1997/013480/07, an authorised financial services provider and administrator of medical schemes. activate the programme
EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
You have comprehensive cover for ADVANCED ILLNESS BENEFIT

CANCER
KE Y F E A T UR E S
A N D B EN EF I TS
Members with cancer have access to a comprehensive palliative care programme.
This programme offers unlimited cover for approved care at home, care
E ME RGE NCY
coordination, counselling services and supportive care for appropriate end-of-life CO V ER AND PM B
clinical and psychologist services. You also have access to a GP consultation to
facilitate your palliative care treatment plan.
S CRE E NI N G A ND
PR E V EN TI O N
PRESCRIBED MINIMUM BENEFITS (PMB)

CONNECTED CARE
Cancer treatment that is a Prescribed Minimum Benefit (PMB), is always covered in full.
DAY-TO-DAY
All PMB treatment costs add up to the cover amount. If your treatment costs more than BENEFITS
AND COVER
the cover amount we will continue to cover your PMB cancer treatment in full.
MATERNITY
ONCOLOGY BENEFIT BENEFITS
CHRONIC
CONDITIONS AND
If you are diagnosed with cancer and once we have approved your cancer treatment, CARE PROGRAMMES
you are covered by the Oncology Care Programme. We cover your approved cancer
treatment over a 12-month cycle. COVER FOR
C A NC E R
We cover the first R200 000. If your treatment costs more than the cover amount, we will
cover up to 80% of the subsequent additional costs. HO S PI TA L
CO VE R A N D
All cancer-related healthcare services are covered up to 100% of the Discovery Health A NNU A L L I M I TS
Rate (DHR). You might have a co-payment if your healthcare professional charges
above this rate.
DAY SUR GE R Y
COLORECTAL CANCER SURGERY

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 You have full cover for approved colorectal cancer surgeries in our network.
treating doctor to confirm that they are using our DSPs for your medicine and C ON TRIB UT ION S
treatment received in rooms or at a treatment facility.
Visit www.discovery.co.za to view the detailed Oncology Benefit guide. EX C LU SI O N S
28
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
HOSPITAL BENEFIT
KE Y F E A T UR E S
If you need to be admitted to hospital

A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
The Priority plans offer cover for hospital stays. There is no overall limit
for the Hospital Benefit. S CRE E NI N G A ND
PR E V EN TI O N
What is the benefit? HOW WE PAY

CONNECTED CARE
If you have to go to hospital, we
We pay for planned hospital stays from your
will pay your hospital expenses. This benefit pays the costs when you are admitted
Hospital Benefit.
There is no overall hospital limit into hospital. DAY-TO-DAY
for the year on any of the plans. We pay for services related to your hospital stay, BENEFITS
AND COVER
However, there are limits to how What we cover including all healthcare professionals, services
much you can claim for some and medicines authorised by the Scheme for your
MATERNITY
treatments. Unlimited cover in any private hospital approved hospital stay. BENEFITS
Contact us in good time before you by the Scheme. The funding of newly licensed If you use doctors, specialists and other healthcare
have to go to hospital. We will let facilities is subject to approval by the Scheme, professionals that we have an agreement with, we CHRONIC
on all health plans. CONDITIONS AND
you know what you are covered will pay for these services in full. We pay up to 200% CARE PROGRAMMES
for. If you don’t contact us before You have cover for planned stays in hospital. of the Discovery Health Rate (DHR) on Classic and
you go, you may be responsible for up to 100% of the DHR on Essential for other
CO V ER FOR
some of the costs. healthcare professionals. CANCE R
You can avoid co-payments by:
H O SP I TA L
GET YOUR CONFIRMATION FIRST Going to a facility in the Day Surgery Network C O V E R A ND
day procedures
Contact us to confirm your hospital stay before you
are admitted (this is known as preauthorisation). Using healthcare professionals that
DAY SUR GE R Y
we have a payment arrangement with.
WHERE TO GO
You can go to any private hospital approved for
funding by the Scheme. The funding of newly
licensed facilities is subject to approval by the
Scheme, on all health plans. An upfront payment
C ON TRIB UT ION S
applies for specific in-hospital procedures including
procedures performed in the Day Surgery Network.
EX C LU SI O N S
29 H OSP I T A L B E NE F I T 1/ 07
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
HOSPITAL
KE Y F E A T UR E S
cover
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
The Priority Plans offer unlimited hospital cover. The table below shows how we pay for your approved hospital admissions:
S CRE E NI N G A ND
PR E V EN TI O N
Healthcare providers and services What we pay
The hospital account The full account at the agreed rate with the hospital
CONNECTED CARE
Specialists we have a payment arrangement with The full account at the agreed rate
Specialists we do not have a payment arrangement Classic plans: up to twice the Discovery Health Rate (DHR) (200%) DAY-TO-DAY
BENEFITS
with and other healthcare professionals Essential plans: up to the Discovery Health Rate (DHR) (100%) AND COVER
X-rays and blood tests (radiology and pathology accounts) Up to the Discovery Health Rate (DHR) (100%)
MATERNITY
Upfront payments for in-hospital procedures: BENEFITS
Upfront payment for a defined list of procedures performed

R5 700 CHRONIC
outside the Day Surgery Network CONDITIONS AND
CARE PROGRAMMES
Defined list of procedures performed in specialist rooms Up to the agreed rate where authorised by the Scheme
You need to pay an amount upfront to the hospital when one of the procedures listed below is performed during a hospital admission, including procedures performed in the Day CO V ER FOR
Surgery Network: CANCE R
Conservative back and neck treatment, adenoidectomy,

R3 850 H O SP I TA L
myringotomy (grommets), tonsillectomy C O V E R A ND
Arthroscopy, functional nasal procedures, hysterectomy
(except for pre-operatively diagnosed cancer), laparoscopy, R9 050
hysteroscopy, endometrial ablation DAY SUR GE R Y
Nissen fundoplication (reflux surgery), spinal surgery (back

R18 600
and neck), joint replacements
If the procedure can be done out of hospital, for example in the doctor’s rooms you won’t have to pay the hospital an amount upfront. If any of these procedures are on the day
surgery procedures list, you will have to pay the higher of the two upfront amounts if the procedure is done at a facility outside of the Day Surgery Network:
MRI and CT Scans We pay the first R3 130 of the scan from day-to-day benefits. We pay the balance of the scan from the Hospital Benefit up to 100% C ON TRIB UT ION S
of the Discovery Health Rate (DHR). For conservative back and neck treatment, you must also pay the first R3 850 of the hospital
account. We pay the balance of the scan from the Hospital Benefit up to 100% of the DHR. Limited to one scan per spinal and
neck region
EX C LU SI O N S
30 H OSP I T A L B E NE F I T S 2/ 07
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
KE Y F E A T UR E S
A N D B EN EF I TS
SCOPES (GASTROSCOPY, COLONOSCOPY, SIGMOIDOSCOPYAND PROCTOSCOPY)

E ME RGE NCY
CO V ER AND PM B
Admissions for scopes Upfront payments for scopes performed outside of the
Day Surgery Network:
Depending on where you have your scope done, you will have to pay the following S CRE E NI N G A ND
amount, and we will pay the balance of the hospital and related accounts from your Where a scope is performed in a facility outside of the Day Surgery Network PR E V EN TI O N
Hospital Benefit. an upfront payment of R5 700 will apply, except if performed in a hospital
outside the Day Surgery Network where an upfront payment of R5 900 will apply.
Upfront payments for scope admissions: CONNECTED CARE
Where both a gastroscopy and colonoscopy are performed the upfront payment
of R7 350 will apply.
Day clinic
Hospital account
account No upfront payment applies:
DAY-TO-DAY
BENEFITS
AND COVER
R5 900, this co-payment If scopes are performed in the doctor’s rooms, as part of a confirmed Prescribed
will reduce to R4 800 if Minimum Benefits (PMB) condition, or the patient is under the age of 12, you will
performed by a doctor MATERNITY
Classic and Essential R3 650 not have to pay any amount upfront. We pay the account from the Hospital Benefit. BENEFITS
who is part of the Scheme’s
value-based network
CHRONIC
CONDITIONS AND
If both a gastroscopy and colonoscopy are performed in the same admission CARE PROGRAMMES
R7 350, this co-payment

CO V ER FOR
will reduce to R6 050 if CANCE R
Classic and Essential R4 450 performed by a doctor
who is part of the Scheme’s H O SP I TA L
value-based network C O V E R A ND
DAY SUR GE R Y
C ON TRIB UT ION S
EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Cover for procedures in the

DAY SURGERY NETWORK

KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
We cover specific procedures that can be done in the Day Surgery Network.
S CRE E NI N G A ND
PR E V EN TI O N
About the benefit How we pay
We cover certain planned procedures in a day surgery We pay these services from your Hospital Benefit. CONNECTED CARE
facility. A day surgery may be inside a hospital, in a day We pay for services related to your hospital stay,
clinic or at a standalone facility. including all healthcare professionals, services
DAY-TO-DAY
and medicines authorised by the Scheme. BENEFITS

AND COVER
If you use doctors, specialists and other healthcare
professionals that we have a payment arrangement
MATERNITY
View the list of day surgery procedures on the next with, we will pay for these services in full. BENEFITS
page. You must contact us to get confirmation of your
procedure (called preauthorisation).
When you need to pay CHRONIC
CONDITIONS AND
CARE PROGRAMMES
If you go to a facility that is not in the Day Surgery
Network, you will have to pay an upfront amount
CO V ER FOR
of R5 700. If any of these procedures form part of the CANCE R
list of procedures with an upfront payment performed
during a hospital admission, as outlined on page 30, HO S PI TA L
the higher of the upfront payments will apply. CO VE R A N D
DA Y SU RGE RY
View all Day Surgery Network facilities using E X T RA B E NE F IT S

Find a healthcare provider on the Discovery app.
C ON TRIB UT ION S
Find a healthcare provider and the Discovery app are brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an EX C LU SI O N S
authorised financial services provider and administrator of medical schemes.
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
The following is a list of procedures that we cover in a day surgery.
B Biopsies G Ganglionectomy R Removal of foreign body KE Y F E A T UR E S

A N D B EN EF I TS
Skin, subcutaneous tissue, soft tissue, Gastrointestinal Subcutaneous tissue, muscle, external
muscle, bone, lymph, eye, mouth, throat, auditory canal under general anaesthesia
Gastrointestinal scopes (oesophagoscopy, E ME RGE NCY
breast, cervix, vulva, prostate, penis, testes CO V ER AND PM B
gastroscopy, colonoscopy, sigmoidoscopy,
S Simple superficial lymphadenectomy
Breast Procedures proctoscopy, anoscopy)
Anorectal procedures (treatment of Skin Procedures S CRE E NI N G A ND
Mastectomy for gynaecomastia PR E V EN TI O N
haemorrhoids, fissure, fistula) Debridement
Lumpectomy (fibroadenoma)
Removal of lesions
Gynaecological Procedures (dependent on site and diameter)
E Ear, nose and throat Procedures CONNECTED CARE
Diagnostic Dilatation and Curettage Simple repair of superficial wounds

Tonsillectomy and/or adenoidectomy
Endometrial ablation DAY-TO-DAY
Repair nasal turbinates, nasal septum U Urological BENEFITS
Diagnostic Hysteroscopy AND COVER
Simple procedures for nose bleed (extensive
Colposcopy with LLETZ Cystoscopy
cautery) to this
Examination under anaesthesia Male genital procedures (circumcision, MATERNITY
Sinus lavage BENEFITS
repair of penis, exploration of testes and
Scopes (nasal endoscopy, laryngoscopy) scrotum, orchiectomy, epididymectomy,
O Orthopaedic Procedures
middle ear procedures (mastoidectomy, excision hydrocoele, excision varicocoele, CHRONIC
CONDITIONS AND
myringoplasty, myringotomy, and/or Arthroscopy, arthrotomy (shoulder, vasectomy) CARE PROGRAMMES
grommets) elbow, knee, ankle, hand, wrist, foot,
temporomandibular joint), arthrodesis
CO V ER FOR
Eye Procedures (hand, wrist, foot) CANCE R
Minor joint arthroplasty (intercarpal,

Cataract surgery
carpometacarpal and metacarpophalangeal, HO S PI TA L
Corneal transplant interphalangeal joint arthroplasty)
CO VE R A N D
Treatment of glaucoma Tendon and/or ligament repair, muscle
Other eye procedures (removal of foreign debridement, fascia procedures (tenotomy,
DA Y SU RGE RY
body, conjunctival surgery (repair laceration, tenodesis, tenolysis, repair/reconstruction,
pterygium), glaucoma surgery, probing capsulotomy, capsulectomy, synovectomy,
& repair of tear ducts, vitrectomy, retinal excision tendon sheath lesion, fasciotomy,
surgery, eyelid surgery, strabismus repair) fasciectomy). Subject to individual
case review
Repair bunion or toe deformity
C ON TRIB UT ION S
Treatment of simple closed fractures and/
or dislocations, removal of pins and plates.
Subject to individual case review EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Benefits with an
ANNUAL LIMIT
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
PR E V EN TI O N
COCHLEAR IMPLANTS, AUDITORY BRAIN SHOULDER JOINT PROSTHESIS MENTAL HEALTH

IMPLANTS AND PROCESSORS CONNECTED CARE
No limit if you get your prosthesis from a provider in 21 days for admissions or up to 15 out-of-hospital
DAY-TO-DAY
R230 400 per person for each benefit. our network or up to R42 950 if you use a provider consultations per person for major affective disorders, BENEFITS
outside our network. anorexia and bulimia and up to 12 out-of-hospital AND COVER
consultations for acute stress disorder accompanied

by recent significant trauma. Three days per approved MATERNITY
BENEFITS
admission for attempted suicide.
INTERNAL NERVE STIMULATORS
PROSTHETIC DEVICES USED IN SPINAL SURGERY 21 days for all other mental health admissions.
CHRONIC
CONDITIONS AND
All mental health admissions are covered in full at CARE PROGRAMMES
R165 300 per person. a network facility. If you go elsewhere, we will pay
There is no overall limit if you get your prosthesis from up to 80% of the Discovery Health Rate (DHR) for CO V ER FOR
our preferred suppliers. If you do not use a preferred the hospital account. CANCE R
supplier, a limit of R26 250 applies for the first level and
R52 500 for two or more levels, limited to one procedure H O SP I TA L
MAJOR JOINT SURGERY per person per year. C O V E R A ND
You have full cover for approved spinal surgery
ALCOHOL AND DRUG REHABILITATION
admissions if you use a provider in our spinal surgery
DAY SUR GE R Y
No limit for planned hip and knee joint replacements network. Planned admissions outside of our network
if you use a provider in our network, or up to 80% of will be funded at up to 80% of the Discovery Health Rate
(DHR) for the hospital account. We pay for 21 days of rehabilitation for each person
the Discovery Health Rate (DHR) if you use a provider
each year. Three days per approved admission per E X T RA B E NE F IT S
outside our network up to a maximum of R30 900 for You also have cover for out-of-hospital conservative
person for detoxification.
each prosthesis for each admission. The network does spinal treatment, see page 36.
not apply to emergency or trauma-related surgeries.
C ON TRIB UT ION S
EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Benefits with an
ANNUAL LIMIT
KE Y F E A T UR E S
A N D B EN EF I TS
E ME RGE NCY
CO V ER AND PM B
DENTAL TREATMENT IN HOSPITAL S CRE E NI N G A ND

PR E V EN TI O N
Dental limit We pay the related accounts, which include the dental surgeon’s account, from your
Hospital Benefit, up to 100% of the Discovery Health Rate (DHR). On Classic plan, we CONNECTED CARE
There is no overall limit for basic dental treatment. However, all dental appliances,
pay anaesthetists up to 200% of the Discovery Health Rate (DHR).
their placement, and orthodontic treatment (including related accounts for
orthognathic surgery) are paid at 100% of the Discovery Health Rate (DHR) and up For members 13 years and older, we cover routine conservative dentistry, such as DAY-TO-DAY
BENEFITS
to 200% of the DHR for anaethetists on Classic plan. We pay these claims from your preventive treatment, simple fillings and root canal treatment, from your available AND COVER
day-to-day benefits, up to an annual limit of R19 150 per person. If you join the day-to-day benefits.
Scheme after January, you won’t get the full limit because it is calculated by counting
MATERNITY
the remaining months in the year. Upfront payment for dental admissions: BENEFITS
Severe dental and oral surgery in hospital

Hospital account Day clinic account CHRONIC
The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with CONDITIONS AND
CARE PROGRAMMES
no upfront payment and no overall limit. Certain procedures are covered in our Day Members 13 years and older:
Surgery Network. This benefit is subject to authorisation and the Scheme’s Rules. R7 050 R4 500
CO V ER FOR
Other dental treatment in hospital Members under 13: CANCE R
You need to pay a portion of your hospital or day clinic account upfront for dental R2 750 R1 240
H O SP I TA L
admissions. This amount varies, depending on your age and the place of treatment. C O V E R A ND
We pay the balance of the hospital account from your Hospital Benefit, up to 100% A NNU A L L I M I TS
of the Discovery Health Rate (DHR).
DAY SUR GE R Y
C ON TRIB UT ION S
EX C LU SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
EXTRA
SPINAL CARE PROGRAMME KE Y F E A T UR E S
BENEFITS
A N D B EN EF I TS
E ME RGE NCY
For conservative spinal treatment out-of-hospital you have access to a defined
on your plan
CO V ER AND PM B
basket of care which includes cover for virtual and face-to-face consultations with an
appropriately registered allied healthcare professional.
S CRE E NI N G A ND
PR E V EN TI O N
You get the following

extra benefits to CONNECTED CARE
enhance your cover. COMPASSIONATE CARE
DAY-TO-DAY
BENEFITS
AND COVER
The Compassionate Care Benefit, gives you access to holistic home-based end-of-life
care up to R70 150 per person in their lifetime, for care not related to cancer.
MATERNITY
BENEFITS
CHRONIC
CONDITIONS AND
CLAIMS RELATED TO TRAUMATIC EVENTS CARE PROGRAMMES
CO V ER FOR
CANCE R
The Trauma Recovery Extender Benefit extends your cover for out-of-hospital claims
Visit www.discovery.co.za to view related to certain traumatic events. Claims are paid from the Trauma Recovery
the detailed benefit guides for each HO S PI TA L
Extender Benefit for the rest of the year in which the trauma occurred, as well as the CO VE R A N D
of the extra benefits on your plan. year after the event occurred. You need to apply for this benefit. A NNU A L L I M I TS
DAY SUR GE R Y
AFRICA EVACUATION COVER E X TRA BE NE F I TS
You have cover for emergency medical evacuations from certain sub-Saharan C ON TRIB UT ION S
African countries back to South Africa.
Pre-existing conditions are excluded.
EX C LU SI O N S
Discovery Home Care is a service provider. Practice 080 000 8000190, Grove Nursing Services (Pty) Ltd
registration number 2015/191080/07, trading as Discovery HomeCare.
36 E X T RA B E N E F I T S 1/ 02
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
EXTRA
KE Y F E A T UR E S
BENEFITS
A N D B EN EF I TS
E ME RGE NCY
on your plan
CO V ER AND PM B
S CRE E NI N G A ND
PR E V EN TI O N
You get the following
extra benefits to
enhance your cover. CONNECTED CARE
DAY-TO-DAY
BENEFITS
AND COVER
INTERNATIONAL SECOND INTERNATIONAL TRAVEL BENEFIT WHO GLOBAL OUTBREAK BENEFIT

OPINION SERVICES MATERNITY
BENEFITS
You have cover for emergency medical costs of up to You have cover up to 100% of the Discovery Health CHRONIC
Through your specialist, you have access to second R5 million per person on each journey while you travel Rate (DHR) for relevant healthcare services, as
CONDITIONS AND
CARE PROGRAMMES
opinion services from Cleveland Clinic for life- outside of South Africa. This cover is for a period of 90 well as a defined basket of care for out-of-hospital
threatening and life-changing conditions. We cover days from your departure from South Africa. healthcare services, related to global World Health
CO V ER FOR
50% for the cost of the second opinion service. Organization (WHO) recognised disease outbreaks CANCE R
We may cover you at equivalent local costs for elective
such as COVID-19. This does not affect your day-
treatment received outside of South Africa, as long as
to-day benefits, where applicable, and in line with HO S PI TA L
the treatment is readily and freely available in South
CO VE R A N D
Prescribed Minimum Benefits (PMB).
Africa and it would normally be covered by your plan. A NNU A L L I M I TS
IN ROOMS PROCEDURES Pre-existing conditions are excluded. For COVID-19 you have access to an online risk
assessment to determine your risk of exposure, as DAY SUR GE R Y
well as the vaccine, screening consultations, testing,
You have cover for a defined list of procedures out-of-hospital management and appropriate
performed in specialist rooms. Cover is up to the supportive treatment as long as the treatment meets
E X TRA BE NE F I TS
agreed rate, where authorised by the Scheme, our benefit entry criteria. In-hospital treatment for
from your Hospital Benefit. approved COVID-19 admissions is covered from the
Hospital Benefit and in accordance with Prescribed
C ON TRIB UT ION S
Minimum Benefits (PMB).
Visit www.discovery.co.za to view the detailed benefit guides for each of the extra benefits on your plan.
EX C LU SI O N S
37 E X T RA B E N E F I T S 2/ 02
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
YOUR CONTRIBUTIONS,
KE Y F E A T UR E S
Medical Savings Account, Annual Thresholds

A N D B EN EF I TS
and Above Threshold Limit E ME RGE NCY

CO V ER AND PM B
S CRE E NI N G A ND
PR E V EN TI O N
Main member Adult Child*

CONNECTED CARE
Contributions (July - December 2021)
Classic Priority R4 041 R3 186 R1 617 DAY-TO-DAY

BENEFITS
AND COVER
Essential Priority R3 472 R2 731 R1 388
Annual Medical Savings Account amounts **

MATERNITY
BENEFITS
Classic Priority R11 778 R9 288 R4 710
Essential Priority R6 066 R4 770 R2 424 CHRONIC

CONDITIONS AND
Annual Threshold amounts **
CARE PROGRAMMES
All plans R17 550 R13 200 R5 850

CO V ER FOR
Limited Above Threshold Benefit amount ** CANCE R
All plans R14 850 R10 600 R5 200

HO S PI TA L
CO VE R A N D
*
We count a maximum of three children when we calculate the monthly contributions, annual Medical Savings A NNU A L L I M I TS
Account, Annual Threshold and Limited Above Threshold amounts.
**
If you join the Scheme after January, you won’t get the full amount because it is calculated by counting the remaining
DAY SUR GE R Y
months in the year.
C O NTRI BU TI O NS
EX C LU SI O N S
38 CO N T RI B U T I O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
EXCLUSIONS
KE Y F E A T UR E S
A N D B EN EF I TS
Healthcare services that are not covered

on your plan E ME RGE NCY
CO V ER AND PM B
The general exclusion list includes: S CRE E NI N G A ND

PR E V EN TI O N
Discovery Health Medical Scheme has Reconstructive treatment and surgery,

including cosmetic procedures and treatments
certain exclusions. We do not pay CONNECTED CARE
for healthcare services related to the Otoplasty for bat ears, port-wine stains
following, except where stipulated and blepharoplasty (eyelid surgery) DAY-TO-DAY
BENEFITS
as part of a defined benefit or under the Breast reductions or enlargements AND COVER
Prescribed Minimum Benefits (PMBs). and gynaecomastia

For a full list of exclusions, please visit Obesity
MATERNITY
BENEFITS
www.discovery.co.za.
Infertility
CHRONIC
Frail care CONDITIONS AND
CARE PROGRAMMES
Medical conditions during Alcohol, drug or solvent abuse
a waiting period Wilful and material violation of the law CO V ER FOR

CANCE R
Wilful participation in war, terrorist activity,

If we apply waiting periods because you have
riot, civil commotion, rebellion or uprising HO S PI TA L
never belonged to a medical scheme or you CO VE R A N D
have had a break in membership of more Injuries sustained or healthcare services A NNU A L L I M I TS
than 90 days before joining Discovery Health arising during travel to or in a country at war
Medical Scheme, you will not have access to
Experimental, unproven or unregistered DAY SUR GE R Y
the Prescribed Minimum Benefits (PMB) during
treatments or practices
your waiting periods. This includes cover for
emergency admissions. If you had a break Search and rescue.
in cover of less than 90 days before joining
We also do not cover the complications or the
Discovery Health Medical Scheme, you may
direct or indirect expenses that arise from any of the
have access to Prescribed Minimum Benefits
exclusions listed above, except where stipulated as C ON TRIB UT ION S
(PMBs) during waiting periods.
part of a defined benefit or under the Prescribed
Minimum Benefits (PMBs).
E X C L U SI O NS
39 E X CL U SI O N S
V A L U E -A DD ED
B EN E F IT S
HO ME
KE Y TE R MS
Exclusive access to
VALUE-ADDED
KE Y F E A T UR E S
A N D B EN EF I TS
OFFERS
E ME RGE NCY
CO V ER AND PM B
S CRE E NI N G A ND
PR E V EN TI O N
Our members have exclusive access to value-added offers outside
of the Discovery Health Medical Scheme benefits and Rules.
CONNECTED CARE
Go to www.discovery.co.za to access these value-added offers.
DAY-TO-DAY
BENEFITS
AND COVER
Savings on personal and Savings on stem cell banking
family care items MATERNITY
You get access to an exclusive offer with Netcells BENEFITS
that gives expectant parents the opportunity
You can sign up for Healthy Care to get savings on
to cryogenically store their newborn baby’s
a vast range of personal and family care products CHRONIC
umbilical cord blood and tissue stem cells for CONDITIONS AND
at any Clicks or Dis-Chem. Healthy Care items include CARE PROGRAMMES
potential future medical use, at a discounted rate.
a list of baby care, dental care, eye care, foot care, sun
care and hand care products, as well as first aid and
CO V ER FOR
emergency items and over-the-counter medicine. CANCE R
Access to Vitality to get healthier
HO S PI TA L
Frames and lenses You have the opportunity to join the world’s leading CO VE R A N D
science-based wellness programme, Vitality, which
You get a 20% discount for frames and lenses at an rewards you for getting healthier. Not only is a healthy
optometrist in your plan’s network of optometrists. lifestyle more enjoyable, it is clinically proven that DAY SUR GE R Y
You will receive the discount immediately when Vitality members live healthier, longer lives.
you pay.
C ON TRIB UT ION S
Vitality is not 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. Limits, terms and conditions apply. Healthy Care is brought to you by Discovery Vitality (Pty) Ltd, registration
number 1997/007736/07, an authorised financial services provider. Netcells is brought to you by Discovery Health (Pty) Ltd, registration number EX C LU SI O N S
1997/013480/07, an authorised financial services provider.
40 V A L UE -A DDD E D O F F E R S
V A L U E - A DDE D
BE NE F I TS
HO ME
KE Y TE R MS
If you have a complaint 01

TO TAKE YOUR QUERY FURTHER KE Y F E A T UR E S

Discovery Health Medical Scheme A N D B EN EF I TS
is committed to providing you with
the highest standard of service and If you have already contacted Discovery Health Medical Scheme and feel that your query has still not been resolved, please complete
your feedback is important to us. E ME RGE NCY
our online complaints form on www.discovery.co.za. We would also love to hear from you if we have exceeded your expectations. CO V ER AND PM B
The following channels are available
for your complaints.
02 S CRE E NI N G A ND
Please go through these steps PR E V EN TI O N
if you have a complaint: TO CONTACT THE PRINCIPAL OFFICER
CONNECTED CARE
If you are still not satisfied with the resolution of your complaint after following the process in Step 1 you are able to escalate your
complaint to the Principal Officer of the Discovery Health Medical Scheme. You may lodge a query or complaint with
DAY-TO-DAY
Discovery Health Medical Scheme by completing the online form on www.discovery.co.za or by e-mailing principalofficer@discovery.co.za. BENEFITS
AND COVER
03
MATERNITY
TO LODGE A DISPUTE BENEFITS
CHRONIC
CONDITIONS AND
If you have received a final decision from Discovery Health Medical Scheme and want to challenge it, you may lodge a formal dispute. CARE PROGRAMMES
You can find more information of the Scheme’s dispute process on the website.
CO V ER FOR
CANCE R
04
TO CONTACT THE COUNCIL FOR MEDICAL SCHEMES HO S PI TA L
CO VE R A N D
Discovery Health Medical Scheme is regulated by the Council for Medical Schemes. You may contact the Council at any stage of the
complaints process, but we encourage you to first follow the steps above to resolve your complaint before contacting the Council. DAY SUR GE R Y
Contact details for the Council for Medical Schemes: Council for Medical Schemes Complaints Unit, Block A, Eco Glades 2 Office Park,
420 Witch-Hazel Avenue, Eco Park, Centurion 0157 | complaints@medicalschemes.co.za | 0861 123 267 | www.medicalschemes.co.za
C ON TRIB UT ION S
EX C LU SI O N S
41
V A L U E -A DD ED
B EN E F IT S
VIEW MORE HEALTH PLANS
EXECUTIVE PLAN COMPREHENSIVE PLANS SAVER PLANS
SMART PLANS CORE PLANS KEYCARE PLANS
Ask Discovery on WhatsApp to get instant answers to your questions, anywhere, anytime.
Just save this number 0860 756 756 on your phone and say ‘Hi’ to starting chatting with us 24/7.
Download the Discovery app
Discovery Health Medical Scheme is regulated by the Council for Medical Schemes.
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 and administrator of medical schemes. This brochure is only a summary
of the key benefits and features of Discovery Health Medical Scheme plans, awaiting 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 to ‘we’ in the context of
benefits, members, payments or cover, in this brochure this is reference to Discovery Health Medical Scheme.
RCK_80253DH_14/05/2021_V3

Discovery Health Medical Scheme Priority Plan Guide 2021

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Discovery Health Medical Scheme Priority Plan Guide 2021

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Priority

LIVE HEALTHY IN EVERY MOMENT

KEY TERMS CONNECTED CARE

EMERGENCY COVER MATERNITY

COVER FOR CANCER CONTRIBUTIONS

CHRONIC ILLNESS BENEFIT (CIB)

plan will determine the amount.

DISCOVERY HOME CARE

H HEALTHID AND COVER

E EMERGENCY MEDICAL CONDITION

to provide medical or surgical treatment would result in serious

M MEDICAL SAVINGS ACCOUNT (MSA)

An emergency does not necessarily require a hospital admission. HO S PI TA L

amount back in equal portions as part of your monthly contribution. We pay

N NETWORKS AND COVER

Surgery Network. professionals who we have

A defined list of 270 diagnoses

If your treatment doesn’t meet the above criteria, we will pay

CONNECTED CARE EXTENSIVE COVER FOR PREGNANCY

We pay your day-to-day medical expenses from the

on the different Priority plans

What is a medical emergency?

are covered in full. An emergency medical condition, CONNECTED CARE

also referred to as an emergency, WHAT WE PAY FOR

If you have an emergency, medical and surgical treatment.

0860 999 911

Click on Emergency Assist DAY SUR GE R Y

Prescribed Minimum Benefits

What are Prescribed Minimum Benefits?

Prescribed Minimum Benefit (PMB) conditions in terms of

of Prescribed Minimum Benefit (PMB) conditions.

You have access to essential

SCREENING AND PREVENTION BENEFITS

tests at our wellness

Clinical entry criteria may apply to these tests: CONNECTED CARE

Pap smear or HPV test for cervical screening.

HEALTH MONITORING MEDICINE ORDERING

from home CONNECTED CARE

from the comfort of your

Introducing your access to

Your benefits through

Clinically appropriate conditions such as chronic

Service Provider (DSP) for administration of defined

(MSA) (DEB) (ATB)

which exceeds the annual benefit limit (where

For more detail on how you are covered visit

Day-to-day We cover your day-to-day healthcare expenses from your

Essential R8 300 R12 500 R15 550 R18 750

Antenatal classes R1 960 for your family

Classic R22 850 R27 700 R33 350 R36 400

Appliances and equipment CONNECTED CARE

Hearing aids Classic R21 350 for your family CHRONIC

ULTRASOUND SCANS AND SCREENINGS or an ear, nose and throat specialist.

or on our website at www.discovery.co.za

CHRONIC What we cover

Your doctor must complete the form online or send

Benefit (CIB) guide.

CHRONIC DISEASE LIST (CDL) CONDITIONS

Chronic conditions covered on all plans If you need chronic dialysis

A Addison’s disease, asthma of the Discovery Health Rate (DHR).

C Cardiac failure, cardiomyopathy, chronic obstructive pulmonary disease, CHRONIC

D Diabetes insipidus, diabetes Type 1, diabetes Type 2, dysrhythmia CO V ER FOR

H Haemophilia, HIV, hyperlipidaemia, hypertension, hypothyroidism

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