Discovery Essential Smart Saver

Cover for Chronic Renal Dialysis as stipulated for the Essential Smart Plan will extend to the Classic Smart Saver and Essential Smart Saver plans.

This Annexure applies to Members on both options in the Smart Saver Series and the same deductible applicable to the Classic Smart Option will apply to the Classic Smart Saver and Essential Smart Saver Options.

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.

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

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

Not covered. This Annexure is not applicable to Members on the Smart Saver Series.

Unlimited consultations with GPs in the Smart network (risk-funded day-to-day benefit), with a R130 co-payment per consultation.

We pay up to the Discovery Health Rate (100%). Certain in-hospital procedures are not covered on this plan. Refer to section 15 for the list of exclusions.

Cover for defined acute medicine categories prescribed by a Smart network GP. Covered from your available Personal Health Fund or Medical Savings Account.

One defined dental check-up at any dentist, dental therapist or oral hygienist with a R195 co-payment for the check-up. Covered up to 100% of the Discovery Health Rate.

Dentistry Advanced out-of-hospital services funded from the 7% Medical Savings Account per Annexure 1 (Healthcare Services Covered from MSA), then self-funded once the MSA is depleted (no ATB).

One eye test at a network optometrist with an upfront payment of R130 for the test.

Radiology Basic out-of-hospital services funded from the 7% Medical Savings Account per Annexure 1 (Healthcare Services Covered from MSA), then self-funded once the MSA is depleted (no ATB).

If it is not related to your admission, we pay the first R4,000 from your available day-to-day benefits and the balance from your Hospital Benefit, up to the Discovery Health Rate. Scans related to conservative back and neck treatment are not covered on this plan.

Pathology out-of-hospital services funded from the 7% Medical Savings Account per Annexure 1 (Healthcare Services Covered from MSA), then self-funded once the MSA is depleted (no ATB).

Cover for sports-related injuries: basic X-rays, two specialist visits and a total of four visits to a physiotherapist, biokineticist, occupational therapist or chiropractor when activated and referred by a Smart network GP. You will have to pay R130 for each X-ray or for each visit. We will cover up to 100% of the Discovery Health Rate for these visits and for specialists who we don’t have a payment arrangement with. On this plan, the benefit is only available to children aged 12 and younger.

Auxiliary Services out-of-hospital services funded from the 7% Medical Savings Account per Annexure 1 (Healthcare Services Covered from MSA), then self-funded once the MSA is depleted (no ATB).

Appliances External out-of-hospital services funded from the 7% Medical Savings Account per Annexure 1 (Healthcare Services Covered from MSA), then self-funded once the MSA is depleted (no ATB).

Cover for over-the-counter (OTC) medicine obtained from a network pharmacy, up to a yearly limit of R605 per family per year.

Cover for contraceptive medicine prescribed by a Smart Network GP and obtained from a network pharmacy. Up to a yearly limit of R2,200 per female beneficiary.

Cover for kids 12 years old and younger: one casualty visit for qualifying injuries. You will have to pay R130 on the Essential Smart Saver for the casualty visit. We will cover the balance of the consultation and related claims up to the Discovery Health Rate.