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DISCOVERY HEALTH EXECUTIVE 2019

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

Additional cover through the Day-to-day Extender Benefit (DEB) for GP consultation fees and kids casualty visits when your Medical Savings Account (MSA) runs out

In Hospital Benefits
Hospital Rate of Payment: 
Covered in full at the rate agreed with the hospital. We cover up to R1 970 a day in a private ward.
Hospitals: 

any private hospital, including private ward cover

Upfront Payments to hospitals: 

dental treatment Hospital Younger than 13 R2 400 13 and older R6 200
Day clinic Younger than 13 R1 100 13 and older R4 000

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 the DHR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
We pay the hospital and related accounts from the Hospital Benefit. If it is done in the doctor’s rooms, we pay the account from your Hospital Benefit.
MRI and CT scans: 
If related to your admission, we pay up to 100% of the DHR from the Hospital Benefit. If not related to your admission, or if for conservative back and neck treatment, we pay from your day-to-day benefits.
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. If your treatment costs more than the cover amount, we will cover up to 80% of the subsequent additional costs.
Joint Replacements: 
We cover planned hip and knee joint replacements in full when you use a provider in our network.
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.

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 applies for the first level and R51 000
for two or more levels, limited to one procedure for each person each year.

Medical and Surgical Appliances: 
Subject to savings. R58 800 for your family. Hearing aids R24 700 for your family.
Maternity Confinements: 
You are covered for your delivery from the Hospital Benefit. private ward cover up to R1 970 for your approved hospital stay for the delivery. You have cover of up to R5 000 for essential registered devices, You are responsible for a 25% co-payment.
In Hospital Dentistry: 
There is no overall limit for basic dental treatment. We pay these claims from your day-to-day benefits, up to an annual limit of R27 300 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
International Travel Benefit: 
cover for emergency medical costs of up to US$1 million for a period of 90 days. Pre-existing conditions excluded
Day-to-day benefits
GP consultations: 

100% of the DHR

Specialist consultations: 

Specialists we have a payment arrangement with Up to the agreed rate
Specialists we don’t have a payment arrangement with 300% of the DHR

Acute medicine: 

100% of the DHR

Over-the-counter (OTC) Medicine: 

90% of the DHR

Optometry benefits: 
Optical* (this limit covers lenses, frames, contact lenses and surgery or any healthcare service to correct refractive errors of the eye) R8 000 for each person
Basic dentistry: 
Subject to savings
Specialised Dentistry: 
Subject to savings.
Orthodontics: 

Subject to saving

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, a pre- or postnatal classes or consults with a registered nurse.
Physiotherapy and Occupational Therapy day to day: 
Subject to savings
Chronic Conditions
Provider: 
Designated Service Provider.
Chronic Conditions: 

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, Isolated growth hormone deficiency, Major depression,muscular dystrophy and other inherited myopathies
Preventative Care Benefits
Preventative Benefits: 

The Screening and Prevention Benefit covers certain tests such as blood glucose, blood pressure, cholesterol, body mass index and HIV screening at one of our wellness providers. We also cover a mammogram every two years, a Pap smear once every three years and a PSA test (prostate screening) each year.

Total Contributions
Total Contribution Main Member: 
6541.00
Total Contribution Adult: 
6541.00
Total Contribution Child*: 
1248.00
Executive Plan
Annual Medical Savings Account
Annual Medical Savings Main Member: 
19620.00
Annual Medical Savings Adult: 
19620.00
Annual Medical Savings Child*: 
3744.00
Monthly Medical Savings
Savings Child*: 
312.00
Savings Adult: 
1635.00
Savings Main Member: 
1635.00
Annual Threshold Amounts
Annual Threshold Main Member: 
22800.00
Annual Threshold Adult: 
22800.00
Annual Threshold Child*: 
4300.00
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: 
4906.00
Risk Contribution Adult: 
4906.00
Risk Contribution Child: 
936.00
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
Medical Aid Plan Name Term: 
Any