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Discovery Health Executive 2018

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Type of Medical Aid Plan: 
Threshold
Medical Aid Year: 
2018
Day to day Benefits: 

High savings account and unlimited Above Threshold Benefit for day-to-day needs. Some day-to-day healthcare services have limits when paid from your Medical Savings Account, pocket and Above Threshold Benefit.

Co-payments: 
None
In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
300% of Scheme Rate
Hospitals: 

Any private hospital.

Upfront Payments to hospitals: 

No upfront payments.

Casualty / Emergency Visits: 
Subject to savings.
Specialists: 
In our network, full cover. Not in our network 300% of the Discovery Health Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
In our network, full cover. Not in our network 200% of the Discovery Health Rate.
Radiology and pathology: 
100 % of Discovery Health Rate.
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
We pay the hospital and related accounts from the Hospital Benefit. If done in the doctor’s rooms, we pay the account from your Hospital Benefit.
MRI and CT scans: 
Paid up to 100% of Discovery Health Rate from the Hospital Benefit.
ICU and High Care: 
100 % of Discovery Health Rate.
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 Discovery Health Rate.
Organ Transplants: 
Subject to pre-authorisation and clinical protocols Unlimited 100 % of scheme rate
Oncology / Cancer: 
We cover the first R400 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 R400 000. Prescribed Minimum Benefits fully covered.
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 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: 

Prosthetic devices used in 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 for the first level and R51 000 for two or more levels applies, limited to one procedure for each person each year. Shoulder joint prosthesis There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R40 000 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 the hospital account. A limit of R30 000 applies to each prosthesis for each admission. This network will not apply to emergency and trauma-related,surgeries.

Medical and Surgical Appliances: 
Subject to savings. R58 800 for your family. Hearing aids R23 700 for your family.
Maternity Confinements: 
100% of Discovery Health Rate. Private ward cover R1 880 per day for your approved delivery. You have cover of up to R5 000 for essential registered devices, for example breast pumps and smart thermometers. You are responsible for a 25% co-payment.
In Hospital Dentistry: 
Upfront payment. Balance of hospital account, dental surgeon & related accounts 100% DHR. Anaesthetists 200% DHR. Dental appliances & orthodontic treatment incl related accounts for orthognathic surgery we pay from your savings limited to R26 200 a person
Take home Medicine: 
Subject to savings.
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.
HIV / AIDS: 
When you register for our HIVCare Programme, you are covered for the care you need, which includes additional cover for social workers. Be assured of confidentiality at all times. You need to get your medicine from a DSP to avoid a 20 % co-payment.
Ambulance Service: 
911
International Travel Benefit: 
$1 million for each person while travelling outside of South Africa, for a period of 90 days. Pre-existing conditions excluded.
Day-to-day benefits
GP consultations: 

Subject to savings.

Specialist consultations: 

Subject to savings.

Acute medicine: 

Subject to savings. Limits apply M - R35 400, M+1 - R41 500, M+2 - R47 500, M+3+ - R53 600

Over-the-counter (OTC) Medicine: 

Subject to savings. These claims do not add up to the Annual Threshold and are not paid from the Above Threshold Benefit.

Optometry benefits: 
Subject to savings. R7 300 for each person. Includes cover for lenses, frames, contact lenses and surgery or any healthcare service to correct refractive errors of the eye. Enjoy savings of 20% for frames and lenses at an optometrist in the network.
Basic dentistry: 
Subject to savings.
Specialised Dentistry: 
Subject to savings.
Orthodontics: 

Subject to savings. Dental appliances and orthodontic treatment R26 200 for each person.

MRI and CT Scans (Out of Hospital): 
Paid from Hospital benefit 100% Discovery Health Rate.
Radiology and Pathology: 
Subject to savings.
Pregnancy benefits: 
You are covered for 12 consults at your gynaecologist, GP or midwife. 1 NIPT screening, 2x 2D ultrasound scans, a defined basket of blood tests, 1 flu vaccination, 5 pre- or postnatal classes or consults with a registered nurse. Paid from Hospital Benefit
Physiotherapy and Occupational Therapy day to day: 
Subject to savings. Limits apply M - R21 200, M+1 - R25 500, M+2 - RR29 800, M+3+ - R35 800
Chronic Conditions
Provider: 
Designated Service Provider.
Chronic Conditions: 

You have cover for the 27 CDL conditions according to the Prescribed Minimum Benefits list and additional chronic conditions. Your condition needs to be approved for it to be covered. Chronic Disease List: 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. Additional chronic conditions: Ankylosing spondylitis, Behςet’s disease, cystic fibrosis, delusional disorder, dermatopolymyositis, generalised anxiety disorder, Huntington’s disease, major depression, muscular dystrophy and other inherited myopathies, myasthenia gravis, obsessive compulsive disorder, osteoporosis, isolated growth hormone deficiency, motor neuron disease, Paget’s disease, panic disorder, polyarteritis nodosa, post-traumatic stress disorder, psoriatic arthritis, pulmonary intestinal fibrosis, Sjögren’s syndrome, systemic sclerosis, Wegener’s granulomatosis

Additional Chronic Conditions: 
Applicable - no medicine list apply
Preventative Care Benefits
Preventative Benefits: 

Covers certain tests at a Discovery Health wellness network provider (blood glucose, blood pressure, cholesterol and body mass index. Mammogram every 2 years, Pap smear every 3 years, PSA (prostate screening test) once a year and HIV screening tests. Flu vaccine. Kids screening covers growth assessment and health and milestone tracking at a Discovery Health wellness network provider.

Total Contributions
Total Contribution Main Member: 
5950.00
Total Contribution Adult: 
5950.00
Total Contribution Child*: 
1134.00
Executive Plan
Annual Medical Savings Account
Annual Medical Savings Main Member: 
17844.00
Annual Medical Savings Adult: 
17844.00
Annual Medical Savings Child*: 
3396.00
Monthly Medical Savings
Savings Child*: 
283.00
Savings Adult: 
1487.00
Savings Main Member: 
1487.00
Annual Threshold Amounts
Annual Threshold Main Member: 
20350.00
Annual Threshold Adult: 
20350.00
Annual Threshold Child*: 
3850.00
Above Threshold Benefit Limits
Above Threshold Benefit Main Member: 
9999999.00
Above Threshold Benefit Adult: 
9999999.00
Above Threshold Benefit Child*: 
9999999.00
Risk Contributions
Risk Contribution Main Member: 
4463.00
Risk Contribution Adult: 
4463.00
Risk Contribution Child: 
851.00
How many times per annum do you and your dependants visit a doctor?: 
40
How much do you spend on Acute medication per annum?: 
More than R 5000
How much do you spend on Chronic medication per annum?: 
More than R 5000
Will you or any of your dependants require specialised Dentistry: 
Yes