Discovery Coastal Saver

Specialists — Premier Rate specialists: Up to a maximum of the Premier Rate. Classic Direct specialists: Where a procedure is performed in the Scheme's day-surgery network, claims will be funded up to a maximum of the agreed Discovery Health Rate. Other specialists: Up to a maximum of 100% of the Discovery Health Rate. Doctors and allied healthcare service providers while hospitalised — Up to a maximum of 100% the Discovery Health Rate.

Accommodation, theatre fees, materials used, prescribed medication for duration of hospitalisation — Up to a maximum of 100% of the Discovery Health Rate in a coastal hospital. Subject to authorisation and/or approval and meeting the Scheme's clinical and managed care criteria.

Statutory Prescribed Minimum Benefits — Basis of cover is contained in Annexure 7. Unlimited. All Prescribed Minimum Benefits (PMBs) to accumulate to available limits. Once benefit limits are reached funding in respect of PMBs will continue to fund in accordance with the basis of cover as contained in Annexure 7.

Stem cell and organ transplants (pre-transplant work-up, in-hospital treatment, post-transplant treatment, immunosuppressive drugs, and donor costs) — In-hospital: Up to a maximum of 100% of the Discovery Health Rate for the hospital account and up to a maximum of 100% of the Discovery Health Rate for related accounts. Out-of-hospital: Treatment related to transplant covered up to a maximum of 100% of the Discovery Health Rate. Basket of care as set by the Scheme specific to transplant.

Chronic Dialysis — Up to a maximum of 100% of the Discovery Health rate at the Scheme's network provider. Subject to authorisation and/or approval and the treatment meeting the Scheme's treatment guidelines and clinical criteria. Drugs paid at 100% of the Discovery Health medication rate. Subject to PMBs.

MRI and CT Scans — Up to a maximum of 100% of the Discovery Health Rate for in-hospital scans performed in respect of treatment related to an authorised admission. Subject to referral by appropriate specialist. If done for conservative back or neck treatment or unrelated to admission, the first R4 000 paid from MSA and the balance from Health Care Cover up to a maximum of 100% of the Discovery Health Rate.

Management of mental health disorders — Up to a maximum of 100% of the Discovery Health Rate for related accounts. Up to a maximum of 100% of the Discovery Health Rate for the hospital account in a network facility. Up to a maximum of 80% of the Discovery Health Rate for the hospital account if a non-network facility is used. Up to 21 days in-hospital, or up to 15 out-of-hospital consultations, for conditions as defined in Annexure A of the Regulations. All other conditions up to 21 days in-hospital.

Home-based healthcare for clinically appropriate chronic and acute treatment and conditions that can be treated at home — In addition to cover contained in Annexure 7, up to a maximum of 100% of the Discovery Health Rate. Home-based virtual care for the elderly — Up to a maximum of 100% of the Discovery Health Rate, for members 65 years and older. Home-based support programme following prolonged NICU admissions — Up to a maximum of 100% of the Discovery Health Rate. Basket of care as set by the Scheme.

Shoulder joint prostheses — Up to a maximum of 100% of the Discovery Health Rate. Network supplier: Unlimited if prosthesis is supplied by the Scheme's network provider. Non-network supplier: R48 500 per prosthesis per admission if prosthesis is not supplied by the Scheme's network provider.

Hip and knee joint replacements — Up to a maximum of 100% of the Discovery Health Rate at a network provider. Network does not apply to any admissions related to trauma. Up to 80% of the Discovery Health Rate for the hospital account if performed at a non-network facility. Up to a maximum of 100% of the Discovery Health Rate for related accounts paid from Health Care Cover for treatment received at a non-network facility. Unlimited at a network provider. Non-network provider: R31 850 per prosthesis per admission.

Spinal prostheses and/or devices — Up to a maximum of 100% of the Discovery Health Rate. Maximum of one procedure per person per year. Network supplier: Unlimited if prosthesis is supplied by the Scheme's network provider. Non-network supplier: R21 600 per person for one spine level if prosthesis is not supplied by the Scheme's network provider; R43 150 per person for two or more spine levels if prosthesis is not supplied by the Scheme's network provider. Where the prostheses and/or device is subject to the spinal surgery being performed in a network facility, up to 80% of the Discovery Health Rate if performed at a non-network facility.

Cardiac stents and balloons — Up to a maximum of 100% of the Discovery Health Rate. Network supplier: Unlimited if supplied by the Scheme's network provider. Non-network supplier: Drug-eluting stent: R14 950 per stent per admission; Bare metal stent limit: R10 650 per stent per admission; Drug-eluting balloon: R13 800 per balloon per admission if not supplied by the Scheme's network provider.

Internal nerve stimulators — Up to a maximum of 100% of the Discovery Health Rate. R192 000 per person per year. The device accumulates to the limit. The balance of the hospital and related accounts do not accumulate to the annual limit.

Cochlear implants and auditory brain implants (including processors) and processor upgrades — Up to a maximum of 100% of the Discovery Health Rate. R252 000 per person per year. Processor upgrade limited to R190 000 per person every three years. Bone Anchored/Transcutaneous Hearing Aids (BAHA) and processor upgrades — Up to a maximum of 100% of the Discovery Health Rate. R150 000 per person per year. Processor upgrade limited to R78 000 per person every three years.

Intra-ocular lenses for cataract surgery — Up to a maximum of 100% of the Discovery Health Rate. Covered in full when supplied by the Scheme's preferred suppliers, otherwise covered up to the Discovery Health Rate for the lens.

Health care services reflected in Annexure 9 in a defined list of network facilities — Up to a maximum of 100% of the Discovery Health Rate at the Scheme's defined list of day-surgery providers. A R7 250 Deductible shall be payable by the beneficiary in respect of the hospital account for elective admissions at a facility which is not a network facility.

Administration of defined intravenous infusions — Up to a maximum of 100% of the Discovery Health Rate at the Scheme's network provider. A 20% co-payment shall be payable by the beneficiary in respect of the hospital account when treatment is received at a provider who is not a network provider. Medicines paid at 100% of the Discovery Health Medication Rate.

Gastroscopies, colonoscopies, proctoscopies and sigmoidoscopies performed in-hospital — Save for the cover contained in Annexure 8, or where indicated and approved for dyspepsia or for children aged twelve years and under, the first R4 650 in respect of the hospital account when performed in a day clinic, or R8 000 in respect of the hospital account when performed in acute facilities, per admission is paid from MSA. Where performed in an acute facility by a doctor who is part of the Scheme's value-based network, the first R6 650 in respect of the hospital account is paid from MSA. Where both a gastroscopy and colonoscopy are performed per admission the first R5 700 (day clinic) or R9 950 (acute facilities) per admission is paid from MSA. Where performed in an acute facility by a value-based network doctor, the first R8 250 is paid from MSA. The balance of the hospital account will be paid from Health Care Cover up to a maximum of 100% of the Discovery Health Rate.

Medication and materials billed by hospital as TTO — Save for cover contained in Annexure 7, TTOs are not covered from Hospital Benefits, but paid from Chronic Illness Benefit where applicable or from the MSA. Subject to Chronic Illness Benefit or MSA, where appropriate.

HIV/AIDS and AIDS-related treatment — Basis of cover contained in Annexure 7. Unlimited. Post-exposure HIV prophylaxis following occupational exposure, traumatic exposure or sexual assault — Up to a maximum of 100% of cost. Unlimited. HIV prophylaxis for mother-to-child transmission — Up to a maximum of 100% of cost. Unlimited.

Advanced Illness Benefit — Up to a maximum of 100% of the Discovery Health Rate. Subject to authorisation and the treatment meeting the Scheme's guidelines and managed care criteria. Unlimited.

International Travel Benefit as set out in Annexure B — Basis of cover as contained in Annexure B. Up to 100% of the cost for in- and out-of-hospital treatment and where such treatment is paid in a foreign currency, the cost will be paid at an exchange rate for such currency as set by the bank at which the Scheme has its account. The first US $150 or €100 in respect of out-of-hospital treatment per person per journey is payable by the member. The balance will be paid from Health Care Cover. R5 000 000 per person per journey for both in- and out-of-hospital treatment.

Non-PMB oncology (Oncology Treatment Programme): 100% of DHR up to a Threshold Claim Amount of R250,000 per person per 12-month cycle, then 80% of DHR with no overall limit. PMB oncology unlimited at PMB level via DSP (ICON/SAOC); voluntary non-network use funded at 80% DHR (20% co-payment).

Not covered. The Specialised Medicine and Technology Benefit is not available on this plan.

Not covered. Assisted Reproductive Therapy Benefit not available on this plan — the benefit is available on the Executive Plan and Comprehensive Series only.

General Practitioners — Up to a maximum of 100% of the Discovery Health Rate. Limited to funds available in MSA.

Pharmacy clinic consultation with or without video call consultation with a General Practitioner — Up to a maximum of 100% of the Discovery Health Rate. Limited to funds available in MSA.

Day-to-day Extender Benefit for: pharmacy clinic consultations with or without video call consultations with a General Practitioner; General Practitioner consultations. Available once the annual MSA has been depleted. Out-of-hospital consultation codes billed by a network pharmacy clinic or GP that meets the digital platform criteria shall be paid from Health Care Cover up to a maximum of 100% of the Discovery Health Rate. Limited to: 3 consultations per principal member; or 6 consultations per family per year.

Specialists — Premier Rate providers: Up to a maximum of the Premier Rate. All other specialists: Up to a maximum of 100% of the Discovery Health Rate. Limited to funds available in MSA.

Prescribed medication — Up to a maximum of 100% of the Discovery Health Medication Rate. Limited to funds available in MSA.

MRI and CT Scans — The first R4 000 in respect of each out-of-hospital MRI and CT scan is payable from MSA and the balance is payable from Health Care Cover up to a maximum of 100% of Discovery Health Rate. Co-payment limited to funds available in MSA. Subject to referral by an appropriate specialist.

Dentistry — Up to a maximum of 100% of the Discovery Health Rate. Limited to funds available in MSA. Subject to the treatment meeting the Scheme's treatment guidelines and managed care criteria.

Dentistry — A Deductible of R8 950 for admissions to hospital or a Deductible of R5 750 for admissions to day-case facilities shall be payable by the beneficiary in respect of the hospital/day-case facility account. The balance of the hospital/day-case facility account will be paid from Health Care Cover up to a maximum of 100% of the Discovery Health Rate. For beneficiaries younger than 13 years a Deductible of R3 470 for admissions to hospital or a Deductible of R1 550 for admissions to day-case facilities... Dentist and related accounts will be paid from Health Care Cover up to a maximum of 100% of the Discovery Health Rate.

External Medical Items (EMI) including those supplied by orthotists and prosthetists — Up to a maximum of 100% of the Discovery Health Rate. Unless part of a defined benefit those listed in Annexure 6 which are paid from MSA at 100% of Discovery Health Rate. Subject to the Scheme's clinical and managed care criteria. Limited to funds available in MSA for items listed in Annexure 6.

All dental appliances and prostheses and the placement of such appliances/prostheses as well as orthodontics (surgical and non-surgical) are paid from MSA up to 100% of the Discovery Health Rate.

All other healthcare practitioners listed in Annexure 1 — Up to a maximum of 100% of the Discovery Health Rate. Limited to funds available in MSA. All payments from MSA subject to funds being available therein.

Radiology and pathology — Up to a maximum of 100% of the Discovery Health Rate. Pathology is subject to a preferred provider network. Where members use a non-preferred provider payment will be made directly to the member. Point-of-care pathology testing is subject to meeting the Scheme's treatment guidelines and managed care criteria.

Gastroscopies, colonoscopies, proctoscopies and sigmoidoscopies performed in-rooms — Up to a maximum of 100% of the Discovery Health Rate when performed at an in-rooms network provider. Save for the cover contained in Annexure 8, where indicated and approved for dyspepsia, and for children aged 12 and under, the first R1 800 is paid from MSA. Where both a gastroscopy and colonoscopy are performed, the first R3 100 is paid from MSA. The balance of the account will be paid from Health Care Cover up to a maximum of 100% of the Discovery Health Rate.

Emergency Medical Services local — Up to a maximum of 100% of the Discovery Health Rate. Inter-hospital transfers subject to authorisation. Unlimited.

Virtual urgent care consultations — In addition to the cover contained in Annexure 7, up to a maximum of 100% of the Discovery Health Rate paid from Health Care Cover for virtual urgent care consultations. 4 consultations per family per year. Consultations in excess of the annual limit or those not meeting the Scheme's clinical entry criteria, paid from MSA.

Management of mental health disorders — Up to a maximum of 100% of the Discovery Health Rate for related accounts. Up to 21 days in-hospital, or up to 15 out-of-hospital consultations, for conditions as defined in Annexure A of the Regulations.

Out-of-hospital healthcare services related to pregnancy and delivery: antenatal classes and/or postnatal visits with a registered nurse; antenatal consultations with a GP, gynaecologist or midwife; prenatal screening or Non Invasive Prenatal Testing (NIPT) or defined chromosome testing; pregnancy scans; a defined basket of pregnancy blood test; postnatal consultation with a GP, gynaecologist or midwife for complications; dietician nutrition assessment; mental health consultation with a GP, psychologist or counsellor; paediatrician, ENT or GP consultations for infants — Up to 100% of the Discovery Health Rate, or agreed rate. Paid from Health Care Cover and is subject to applicable limits. Services in excess of the limit paid from MSA. Limits: antenatal classes and/or postnatal visits: 5 per pregnancy; antenatal consultations: 8 per pregnancy; prenatal screening/NIPT: 1 per pregnancy; pregnancy scans: 2 per pregnancy; blood tests: 1 routine basket per pregnancy; postnatal consultations for complications: 1 per delivery; dietician nutrition assessment: 1; mental health consultations: 2; consultations for infants: 2 per child. 3D and 4D scan will be paid up to the maximum of the cost of a 2D scan.

Pregnancy scans — Once the out-of-hospital cover related to pregnancy and delivery is reached, up to a maximum of 100% of Discovery Health Rate. Limited to funds available in MSA. 3D and 4D scan will be paid up to the maximum of the cost of a 2D scan. Non-invasive Prenatal Screening Test or defined chromosome testing — Up to a maximum of 100% of the Discovery Health Rate. Limited to funds available in MSA. New born screening — Up to a maximum of 100% of the Discovery Health Rate. Limited to funds available in MSA.

Medication for the chronic Prescribed Minimum Benefit conditions — Save for medication contemplated in Rule 15.18 of the Main Body of the Rules, basis of cover contained in Annexure 7. Subject to the Scheme's protocols, clinical entry criteria and drug utilisation review. As contained in Annexure 7.

Trauma benefit services covered under this benefit include: Allied healthcare services; External medical items; Hearing aids; Prescribed Medicine. Hearing aids: Limited to R17 850 per family per year.

Allied and therapeutic healthcare services including: Acousticians, biokineticists, chiropractors, dieticians, homeopaths, nursing providers, occupational therapists, physiotherapists, podiatrists, psychologists, psychometrics, counsellors, social workers, speech and hearing therapists limited to: Member: R10 100; M + 1 dependant: R15 250; M + 2 dependants: R18 950; M + 3 dependants or more: R22 800. Up to 6 additional counselling sessions per beneficiary per year.

Screening Benefit A - Group of tests consisting of blood glucose test, blood pressure test, cholesterol test and Body Mass Index (BMI) — Up to a maximum of the Discovery Health Rate for group of tests at a network provider. Subject to meeting the Scheme's clinical entry criteria. Unlimited.

Screening Benefit B - Consist of appropriate tests (including self-sampling kits, where appropriate) and as determined by the Scheme: HIV screening, Mammogram, Prostate-Specific Antigen (PSA), colorectal and cervical cancer screening — Up to a maximum of 100% of the Discovery Health Rate for test code. Tests in excess of annual limit paid from MSA, subject to PMBs. Limits: One Mammogram every 2 years, one Pap Smear every 3 years or one HPV test every 5 years and one PSA test per person per year; One faecal occult blood test or immunochemical test every 2 years per person for persons between the ages of 45 to 75 years. Note: Consultation limited to funds available in MSA.

Preventative Benefit - Pneumococcal Vaccination — Up to a maximum of 100% of the Discovery Health Medication Rate for the vaccination. Up to 2 pneumococcal vaccine doses per person per lifetime. Pneumococcal vaccines in excess of the limit paid from MSA. Preventative Benefit - Seasonal Influenza Vaccination — Up to a maximum of 100% of the Discovery Health Medication Rate for the vaccination. One seasonal influenza vaccine per person per year. Seasonal flu vaccines in excess of the annual limit paid from MSA. Note: Consultation and other healthcare services to administer the vaccine, paid from MSA.

Screening Benefit C - Group of age appropriate tests including but not limited to growth assessment, blood pressure and health and milestone tracking — Up to a maximum of 100% of the Discovery Health Rate at a network provider, for children between the ages of 2 and 18. Screening Benefit D – Group of age appropriate screening tests — Up to a maximum of 100% of the Discovery Health Rate at a network provider, for members 65 years and older. Additional screening assessment or consultation — Up to a maximum 100% of the Discovery Health Rate at an accredited network provider. One consultation per person per year.