Discovery Essential Dynamic Smart

DRUG ELUTING BALLOONS: Covered in full when using a network supplier, otherwise a limit of R13,800 will apply per admission on all plans.

SHOULDER JOINT PROSTHESES: Covered in full when using a network supplier; otherwise a limit of between R46,000 and R53,000 will apply, depending on the member’s chosen health plan. On Essential Smart, Essential Dynamic Smart, Active Smart and KeyCare plans joint replacements are covered as PMB only.

On Essential Smart, Essential Dynamic Smart, Active Smart and KeyCare plans joint replacements are covered as PMB only.

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 via DSP; non-network 80% DHR (20% co-pay).

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.

Up to a maximum of 100% of 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. Unlimited. Subject to authorisation and/or approval and the meeting the Scheme's clinical and managed care criteria. Doctors and allied healthcare service providers while hospitalised: Up to a maximum of 100% of the Discovery Health Rate. Unlimited

Gastroscopies, colonoscopies, proctoscopies, sigmoidoscopies performed in-hospital: Save for the cover contained in Annexure 8, or where indicated and approved for dyspepsia or for children aged 12 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 paid by the beneficiary. 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 by the beneficiary. Where both a gastroscopy and colonoscopy are performed per admission the first R5 700 in respect of the hospital account when performed in a day clinic, or R9 950 in respect of the hospital account when performed in acute facilities, per admission is paid by the beneficiary. Where performed in an acute facility by a doctor who is part of the Scheme's value-based network, the first R8 250 in respect of the hospital account is paid by the beneficiary.

Administration of defined intravenous infusions: 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.

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. A R5 450 deductible shall be payable by the beneficiary in respect of the hospital account for elective admissions at any private facility that is not a designated service provider.

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. Subject to Chronic Illness Benefit

HIV/AIDS and AIDS-related treatment: Basis of cover is 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. Subject to PMB's. Unlimited. HIV prophylaxis for mother-to-child transmission: Up to a maximum of 100% of cost. Unlimited

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

Cataract surgery: Up to a maximum of 100% of the Discovery Health Rate for the hospital account at a network facility. 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. Unlimited

Pre-operative assessment for the following list of major surgeries: arthroplasty, colorectal surgery, coronary artery bypass graft, radical prostatectomy and mastectomy: Up to a maximum of 100% of the Discovery Health Rate. Basket of care as set by the Scheme

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 R12 650 Deductible shall be payable by the beneficiary in respect of the hospital account for elective admission at a facility which is not a network facility. Medicines paid at 100% of the Discovery Health Medication Rate.

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 if not supplied by the Scheme's network provider. Bare metal stent limit: R10 650 per stent per admission if not supplied by the Scheme's network provider. Drug-eluting balloon: R13 800 per balloon per admission if not supplied by the Scheme's network provider

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

Management of mental health disorders: 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 and related accounts 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

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. Unlimited. If done for conservative back or neck treatment or unrelated to admission, MRI/CT scan payable by member.

Chronic Dialysis: Basis of cover is contained in Annexure 7. Subject to PMBs

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. A R5 450 deductible shall be payable by the beneficiary in respect of the hospital account for elective admissions at any private facility that is not a designated service provider. Basket of care as set by the Scheme. Home-based virtual care for the elderly: Up to a maximum of 100% of the Discovery Health Rate, for members 65 years and older.

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

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 ... 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

International clinical review service: Up to a maximum of 75% of the cost of the consultation. Subject to the Scheme's preferred provider, protocols and clinical entry criteria. Unlimited. Benefit for out-of-hospital management and appropriate supportive treatment of specific global World Health Organisation (WHO) recognised disease outbreaks: COVID-19, Mpox: In addition to cover contained in Annexure 7, up to a maximum of 100% of the Discovery Health Rate. Basket of care as set by the Scheme per condition.

Not covered. A limit of R150,000 will apply for bone-anchored hearing aids, with a limit of R78,000 for processor upgrades where a non-network supplier is used. The device will be funded in full when a network supplier is used. The bone-anchored hearing aid and processor upgrades are not covered on the KeyCare series, Essential Smart, Essential Dynamic Smart and Active Smart plans.

Not covered. The cochlear processor upgrade limit will be set at R190,000 and applies to all plans except Essential Smart, Essential Dynamic Smart, Active Smart and KeyCare plans where cochlear implants are excluded.

Out-of-hospital consultation codes billed by Smart Network GPs shall be paid from Health Care Cover up to a maximum of 100% of the Discovery Health Rate, and subject to a R130 co-payment per consultation. This co-payment does not apply to video call consultations. Any other healthcare services related to consultations are payable by the member. GPs in the network: Unlimited, subject to a R130 co-payment per consultation

Not covered. GPs not in the network: No cover except in emergencies

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.

Dental check-up: Up to a maximum of 100% of the Discovery Health Rate subject to a R195 co-payment by the member. One check-up per beneficiary per year

Severe dental and oral procedures reflected in Annexure 3: 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 hospital account. Where such event is also subject to Annexure 9, a Deductible amount shall be payable by the beneficiary in respect of the hospital account for elective admissions at a facility which is not a network facility.

Eye test: Up to a maximum of 100% of the Discovery Health Rate at a network provider. Subject to a R130 co-payment by the member. One test per beneficiary per year

Over-the-counter medication (schedule 0 - 2 medication): Up to 100% of the Discovery Health Medicine Rate at a network pharmacy. A defined list of exclusion categories apply. R605 per family per year

Medication for the chronic Prescribed Minimum Benefit conditions: Save for medication contemplated in clause 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

Radiology & Pathology: Up to a maximum of 100% of the Discovery Health Rate. Unlimited. 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.

Radiology & Pathology: Up to a maximum of 100% of the Discovery Health Rate. Unlimited.

Not covered. 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, MRI/CT scan payable by member.

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 by the beneficiary. Where both a gastroscopy and colonoscopy are performed, the first R3 100 is paid by the beneficiary. The balance of the account will be paid from Health Care Cover up to a maximum of 100% of the Discovery Health Rate.

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.

Out-of-hospital healthcare services related to pregnancy and delivery: Up to 100% of the Discovery Health Rate, or agreed rate. Paid from Health Care Cover and is subject to applicable limits. Services: antenatal classes and/or postnatal visits: 5 consultations or classes per pregnancy and/or delivery; antenatal consultations: 8 per pregnancy; prenatal screening, including chromosome testing or Non Invasive Prenatal Testing (NIPT): 1 per pregnancy; pregnancy scans: 2 per pregnancy; blood tests: 1 routine basket of pregnancy tests per pregnancy; postnatal consultations for complications post delivery: 1 per delivery; dietician nutrition assessment: 1 during pregnancy or after delivery; mental health consultations: 2 during pregnancy or after delivery; consultations for infants: 2 per child. 3D and 4D scan will be paid up to the maximum of the cost of a 2D scan.

Management of mental health disorders: Up to a maximum of 100% of the Discovery Health Rate for related accounts in a network facility. 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

Not covered. External Medical Items (EMI) including those supplied by orthotists and prosthetists: Up to a maximum of the Discovery Health Rate. Unless part of a defined benefit those listed in Annexure 6 are for member's own account. Those not listed in Annexure 6: Unlimited. No cover for out-of-hospital

Home-monitoring devices for clinically appropriate chronic and acute conditions: Up to a maximum of 100% of the Discovery Health Rate paid from Health Care Cover. Up to R4 850 per person per year. The device must be approved by the Scheme, subject to the Scheme's protocols and clinical and benefit entry criteria.

Point-of-care medical devices: Up to a maximum of 75% of the Discovery Health Rate paid from Health Care Cover. One device per family. The device must be approved by the Scheme, subject to the Scheme's protocols and clinical and benefit entry criteria.

Hearing aids: Limited to R17 850 per family per year

Trauma benefit services covered under this benefit include: Allied healthcare services ... Allied and therapeutic healthcare services including: o 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

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 are payable by the member.

Over and above the DTPMB entitlement, this benefit also covers certain out-of-hospital healthcare services arising from an emergency, trauma-related event resulting in the following PMB conditions: Paraplegia, Quadriplegia, Near-drowning related injury, Severe anaphylactic reaction, Poisoning, Crime-related injury, Severe burns, External and internal head injuries, Loss of limb. Trauma benefit services covered: Allied healthcare services, External medical items, Hearing aids, Prescribed Medicine. External Medical Items: Limited to R28 900 per family per year, except for prosthetic limbs which shall be subject to a limit of R107 650 per person per year; Hearing aids: Limited to R17 850 per family per year; Prescribed Medicine limited to: Member R19 700, M + 1 dependant R23 350, Member + 2 dependants R27 700, Member + 3 dependants or more R33 700.

Not covered. No contraceptive benefit stated in the plan brochure; all claims not paid by Health Care Cover or the Chronic Illness Benefit are for the beneficiary's account.

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 100% of the Discovery Health Rate for group of tests at a network provider. 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. Appropriate HIV screening tests as determined by the Scheme – Unlimited. 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

Additional cover for Mammogram, breast MRI and biopsy, BRCA testing, colonoscopy and cervical cancer screening: Up to a maximum of 100% of the Discovery Health Rate for test code. Basket of care as set by the Scheme. Once off BRCA testing and colonoscopy

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. Unlimited

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. Unlimited

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

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 payable by the member. Note: Consultation and other healthcare services to administer the vaccine, paid by member.

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. Note: Pneumococcal vaccines in excess of the limit and consultation and other healthcare services to administer the vaccine, paid by the member.