Are you prepared to use designated hospitals?:
Hospital Rate of Payment:
Unlimited at 100% of Discovery Health Rate (DHR)
Upfront Payments to hospitals:
Admissions to a facility outside of the day surgery network, where applicable, result in a R5 700 upfront payment. Where these procedures form part of the list of in-hospital procedures with an upfront payment, the higher of the upfront payments will apply
Casualty / Emergency Visits:
Emergencies are covered in full, if the treatment meets the Discovery Health criteria
Specialists:
Full cover for specialists we have a payment arrangement with. Other specialists at 100% of DHR
Other healthcare professionals eg. Physio, Occupational, Dietician:
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
You pay R3 650 upfront and Discovery pays the balance of the account, if done in the day surgery network. If both a colonoscopy & gastroscopy are done in the same admission the amount increases to R4 450. No upfront payment if done in doctor's rooms
MRI and CT scans:
As part of an approved admission, the first R3 130 of the scan is paid from day-to-day benefits. If not related to your admission or for conservative back and neck treatment, you also pay R3 850 upfront. The balance is paid at 100% of DHR. Limits apply
Dialysis:
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 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:
You pay R18 600 upfront. No overall limit if you get your prosthesis from a preferred supplier. Limited to 1 procedure per beneficiary per annum
Joint Replacements:
You pay R18 600 upfront. No overall limit if you use a provider in the network
Medical and Surgical Appliances:
Limited to available day-to-day benefits and annual benefit limits. External items up to R26 450 per family. Hearing aids up to R14 750 per family
Maternity Confinements:
Subject to pre-authorisation. Unlimited at 100% of DHR
In Hospital Dentistry:
Upfront payments for dental admissions, dependant on age & place of treatment. Balance of hospital & related accounts are paid at 100% of DHR. Limited to R18 600 pppa. Severe Dental & Oral Surgery has a separate benefit for a defined list of procedures
Take home Medicine:
Subject to day-to-day 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
HIV / AIDS:
Subject to registration on the HIV programme. Choose a Premier Plus HIV Network GP and Specialist to manage your condition and avoid a 20% co-payment
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
