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Essential Core

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

No benefit

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Hospital Rate of Payment: 
Unlimited at 100% of Discovery Health Rate (DHR)

Any facility approved by Discovery Health. A defined list of procedures are covered in a Day Surgery Network facility

Upfront Payments to hospitals: 

Admissions to a facility outside of the Day Surgery Network, where applicable, results in a R5 500 upfront payment

Casualty / Emergency Visits: 
Emergencies are covered in full, if the treatment meets the Discovery Health criteria
Full cover for specialists we have a payment arrangement with. Other specialists at 100% of DHR
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited at 100% of DHR
Radiology and pathology: 
Unlimited at 100% of DHR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
You pay the first R5 000 of the hospital account. An upfront amount of R6 250 will apply if both a colonoscopy and gastroscopy are performed in the same admission
MRI and CT scans: 
100% of DHR, if done as part of an approved admission
ICU and High Care: 
Unlimited at 100% of DHR
Covered in full if treatment is approved and you use a network provider. If a non-network provider is used Discovery pays up to 80% of the DHR
Organ Transplants: 
Cover for transplant surgery explained on authorisation request. Discovery pay for appropriate, approved work-up costs for recipient, procurement of organ and necessary tests done on donor before harvesting organ, even if donor is not a member of DH
Oncology / Cancer: 
Cover for the first R200 000 of your approved cancer treatment over a 12-month cycle in full at 100% of DHR. Cancer treatment that is a PMB is covered in full and adds up to the cover amount. 80% cover for additional costs
Neck and Back Operations: 
No overall limit if you get your prosthesis from a preferred supplier. Limited to 1 procedure per beneficiary per annum
Joint Replacements: 
No overall limit if you use a provider in the network

Cochlear implants, auditory brain implants and processors; R233 700 per beneficiary, per benefit: Internal nerve stimulators; R160 500 per beneficiary: Shoulder Joint; if you use a non-network provider, up to R41 700: Major joint surgery; if you use a non-network provider, 80% of DHR up to a maximum of R30 000 per prosthesis, per admission: Spinal surgery; if you use a non-network provider, limited to R25 500 for 1st level and R51 000 for 2 or more levels

Medical and Surgical Appliances: 
No benefit
Maternity Confinements: 
Subject to pre-authorisation. Unlimited at 100% of DHR
In Hospital Dentistry: 
Upfront payments for dental admissions, dependant on age and place of treatment. Balance of hospital and related accounts are paid from hospital benefit at 100% of DHR. Severe Dental & Oral Surgery has a separate benefit for a defined list of procedures
Take home Medicine: 
No benefit
Rehabilitation, Hospice and Step-down facilities: 
21 days of rehabilitation per person per annum. 3 days per approved admission per person for detoxification
Treatment for Mental Health: 
Covered in full at a network facility, or up to 80% of DHR at non-network facilities. Protocols apply. Up to 21 days for admissions or up to 15 out-of-hospital consultations pp
Subject to registration on the HIV programme. Choose a Premier Plus HIV Network GP and Specialist to manage your condition to avoid a 20% co-payment
Ambulance Service: 
Netcare 911
International Travel Benefit: 
Cover up to R5 million per person, per journey, for a period of 90 days, for emergency medical costs while travelling outside of SA
Day-to-day benefits
GP consultations: 

No benefit

Specialist consultations: 

No benefit

Acute medicine: 

No benefit

Over-the-counter (OTC) Medicine: 

No benefit

Optometry benefits: 
No benefit
Basic dentistry: 
No benefit
Specialised Dentistry: 
No benefit

No benefit

MRI and CT Scans (Out of Hospital): 
No benefit
Radiology and Pathology: 
No benefit
Pregnancy benefits: 
8 antenatal consultations, 2 x 2D scans, including 1 x nuchal translucency test. A defined basket of blood tests. 5 x antenatal or postnatal classes or consultations with a registered nurse up until 2 years after giving birth
Physiotherapy and Occupational Therapy day to day: 
No benefit
Chronic Conditions
MedXpress or a MedXpress network pharmacy
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to approval by the Chronic Illness Benefit

Additional Chronic Conditions: 
Preventative Care Benefits
Preventative Benefits: 

Screening tests for adults and children at a wellness network provider. Age specific tests for: pap smear, mammogram, prostate and HIV screening tests. Flu vaccine during pregnancy and for members > 65 years. Bowel cancer screening tests for members 45-75 years

Total Contributions
Total Contribution Main Member: 
Total Contribution Adult: 
Total Contribution Child*: 
Essential Core
Risk Contributions
Risk Contribution Main Member: 
Risk Contribution Adult: 
Risk Contribution Child: