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DISCOVERY HEALTH CLASSIC SMART 2019

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Type of Medical Aid Plan: 
Hybrid
Medical Aid Year: 
2019
Day to day Benefits: 

Unlimited Smart Network GP consultations, with a R50 payment for each consultation
One eye test at a network optometrist, with a R50 payment for the test. Covered up to 100% of the DHR
One defined dental check-up at any dentist, with a R100 payment for the check-up. Covered up to 100% of the DHR
Cover for defined acute medicine categories when prescribed by your network GP, with a R10 payment for each medicine item
Cover for over-the-counter (OTC) medicine obtained from a network pharmacy, up to an annual limit of R630 per family per year
Cover for sports-related injuries: basic X-rays, two specialist visits and a total of four visits to a physiotherapist, biokineticist or chiropractor when referred by a Smart Network GP. You will have to pay R100 for each X-ray or for each visit. We will cover up to 100% of the DHR for these visits and specialists who we don’t have a payment arrangement with

In Hospital Benefits
Hospital Rate of Payment: 
Covered in full at the rate agreed with the hospital
Hospitals: 

Unlimited private hospital cover in the Smart Hospital Network

Upfront Payments to hospitals: 

Scopes: You must pay the first R4 550 of the hospital account. The balance of the hospital account and related accounts will be paid from the Hospital Benefit. If done in the doctor’s rooms, you won’t have to pay an amount upfront. If performed outside of the day surgery network an upfront payment of R8 800 will apply.

MRI and CT scans: If not related to your admission or if for conservative back and neck treatment, you will have to pay the first R2 900 and the balance will be paid from the Hospital Benefit.

Specialists: 
Specialists we have a payment arrangement with Full cover Specialists we don’t have a payment arrangement with and other healthcare professionals 200% of the Discovery Health Rate (DHR)
Other healthcare professionals eg. Physio, Occupational, Dietician: 
200% of the Discovery Health Rate (DHR)
Radiology and pathology: 
100% of the Discovery Health Rate (DHR)
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
You must pay the first R4 550 of the hospital account. The balance of the hospital account and related accounts will be paid from the Hospital Benefit. If done in the doctor’s rooms, you won’t have to pay an amount upfront.
MRI and CT scans: 
If related to your admission, we cover your scan up to 100% of the DHR from the Hospital Benefit.
Dialysis: 
We cover these expenses in full if we have approved your treatment plan and you use a provider in our network. If you go elsewhere, we will pay up to 80% of the DHR.
Oncology / Cancer: 
We cover the first R200 000 of the approved cancer treatment in full, over a 12-month cycle. You will be required to pay 20% of the cost on all further treatment once costs for cancer treatment go over R200 000. Prescribed Minimum Benefits are covered in
Neck and Back Operations: 
There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R25 500 applies for the first level and R51 000 for two or more levels, limited to one procedure for each person each year
Joint Replacements: 
There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, certain limits may apply to each prosthesis.
Prosthesis: 

Shoulder joint prostheses There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R41 700 applies to each prosthesis.

Major joints surgery we cover planned hip and knee joint replacements in full when you use a provider in our network. If you go elsewhere, we will pay up to 80% of the Discovery Health Rate (DHR) for the hospital account. A limit of R30 000 applies to each prosthesis for each admission.

Spinal surgery There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R25 500 applies for the first level and R51 000 for two or more levels, limited to one procedure for each person each year.

Rehabilitation, Hospice and Step-down facilities: 
21 days for each person
Treatment for Mental Health: 
21 days for admissions or up to 15 out-of-hospital consultations for each person for major affective disorders, anorexia and bulimia, and up to 12 out-of-hospital consultations for acute stress disorder accompanied by recent significant trauma.
International Travel Benefit: 
Cover up to R5 million for each person on each journey for emergency medical costs while travelling outside of South Africa, for a period of 90 days from your departure from South Africa. Specific rules apply and pre-existing conditions are excluded.
Day-to-day benefits
GP consultations: 

You get unlimited GP consultations when visiting a GP in the Smart Network GP. You pay R50 of the consultation fee with the balance of this fee covered up to the Discovery Health Rate (DHR). Video consultations with your Smart Network GP are covered in full up to the DHR.

Acute medicine: 

you get cover for certain acute medicine, with a R10 payment for each medicine item. This is limited to 12 prescriptions for each person each year for the defined acute medicine categories. You need to get your medicine from a network pharmacy.

Over-the-counter (OTC) Medicine: 

You get cover for over-the-counter (OTC) medicine obtained from a network pharmacy, up to a limit of R630 on Classic per family per year. The categories of medicine we cover can

be found on www.discovery.co.za.

Optometry benefits: 
You can go for one eye test at an optometrist in the Smart Optometry Network. You pay R50
Basic dentistry: 
You can go for one defined dental check-up at any dentist. You pay R100 of the consultation fee and the balance of this fee will be covered up to the Discovery Health Rate (DHR).
MRI and CT Scans (Out of Hospital): 
you must pay the first R2 900 of MRI or CT scan. We cover the balance of the scan from your Hospital Benefit, up to the Discovery Health Rate (DHR).
Pregnancy benefits: 
8 consultations at gynaecologist, Smart network GP or midwife. 1 nuchal translucency/NIPT screening. 2 2D scans. 3D/4D scans at 2D rate. 5 pre- or postnatal classes or consultations. 1 lactation, nutritional assessment & 2 mental healthcare consultations.
Chronic Conditions
Chronic Conditions: 

You have cover for the 27 CDL conditions according to the Prescribed Minimum Benefits list. Your condition needs to be approved for it to be covered. Addison’s disease, asthma, bipolar mood disorder, bronchiectasis, cardiac failure, cardiomyopathy, chronic obstructive pulmonary disease, chronic renal disease, coronary artery disease, Crohn’s disease, diabetes insipidus, diabetes Type 1, diabetes Type 2, dysrhythmia, epilepsy, glaucoma, haemophilia, HIV, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus, ulcerative colitis

Total Contributions
Total Contribution Main Member: 
1794.00
Total Contribution Adult: 
1415.00
Total Contribution Child*: 
717.00
Classic Smart
Risk Contributions
Risk Contribution Main Member: 
1794.00
Risk Contribution Adult: 
1415.00
Risk Contribution Child: 
717.00