Discovery KeyCare Core

Hospitalisation in Full Cover network Up to a maximum of 100% of the Discovery Health Rate of the hospital account. Subject to authorisation and/or approval and the meeting the Scheme's clinical and managed care criteria. Unlimited

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. Subject to authorisation and/or approval and the treatment meeting the Scheme's clinical criteria.

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. Subject to authorisation and/or approval, the Scheme's designated service provider (where applicable) and the treatment meeting the Scheme's treatment guidelines and clinical and benefit entry criteria. 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. Subject to the Scheme's clinical entry criteria, treatment guidelines and protocols. Basket of care as set by the Scheme.

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. Subject to authorisation and/or approval and the treatment meeting the Scheme's clinical entry criteria, treatment guidelines and protocols. Basket of care as set by the Scheme.

Statutory Prescribed Minimum Benefits Basis of cover is contained in Annexure 7. 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. Unlimited

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. Medicines paid at 100% of the Discovery Health Medication Rate. Unlimited

Organ transplant Cover only in a public facility according to the PMB. Subject to Regulation 8 (3). Unlimited

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 for conditions as defined in Annexure A of the Regulations. All other conditions up to 21 days in-hospital.

Drug and alcohol rehabilitation Up to a maximum of 100% of the Discovery Health Rate. 21 days in-hospital treatment per person per year.

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. Unlimited

Prophylaxis for mother-to-child transmission Up to a maximum of 100% of cost. Unlimited

HIV Management for members registered on the Scheme's Disease Management Programme Basis of cover is contained in Annexure 7. Up to 100% of the Discovery Health Rate for services covered in the Scheme's basket of care if referred by the Scheme's DSP and enrolled on the Scheme's Disease Management Programme for HIV. Up to 80% of the Discovery Health Rate if not registered on the Scheme's Disease Management Programme. Basket of care as set by the Scheme.

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: The device accumulates to the limit. Drug-eluting stent: R8 150 per stent per admission if not supplied by the Scheme's network provider. Bare metal stent limit: R6 400 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.

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. Subject to authorisation and the treatment meeting the Scheme's treatment guidelines and clinical criteria. 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

MRI and CT Scans Up to a maximum of 100% of Discovery Health Rate for in-hospital scans performed in respect of treatment related to an authorised admission. Subject to the treatment meeting the Scheme's treatment guidelines and managed care criteria. Scan must be performed by a specialist at a network hospital. Unlimited

TTO medicine (medicine to take home) Save for cover contained in Annexure 7, up to a maximum of 100% of Discovery Health Medication Rate. R230 per hospital admission.

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. Subject to the Scheme's preferred provider (where applicable), protocols and the condition and treatment meeting the Scheme's entry criteria and guidelines. Basket of care as set by the Scheme per condition.

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

Chemotherapy, Radiotherapy and Oncological treatment — Basis of cover is contained in Annexure 8. Unlimited, save as provided for elsewhere in these Rules.

Not covered. Specialised Medicine and Technology treatment contemplated in clause 15.18 of the Main Body of the Rules — No cover. Not applicable.

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. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

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. The device must be approved by the Scheme, subject to the Scheme's protocols and clinical and benefit entry criteria. Up to R4 850 per person per year.

Blood glucose monitoring device Any beneficiary approved and registered on the Scheme's Chronic Illness Benefit for Diabetes is covered up to 100% of the Discovery Health Rate, paid from Health Care Cover. The device must be approved by the Scheme, subject to Scheme protocols and clinical entry criteria. 1 per beneficiary per year limited to the home-monitoring device limit as stipulated in Table A.

Other providers Up to a maximum of 100% of the Discovery Health Rate. Unlimited

Medication for the chronic Prescribed Minimum Benefit condition. Save for medication contemplated in clause 15.18 of the Main Body of the Rules, basis of cover contained in Annexure 7. Subject to Scheme protocols, clinical entry criteria and medicine utilisation review. As contained in Annexure 7.

Diabetes Management for members registered on the Scheme's Disease Management Programme Basis of cover is contained in Annexure 7. Up to 100% of the Discovery Health Rate for services covered in the Scheme's basket of care if referred by the Scheme's DSP and enrolled on the Scheme's Disease Management Programme for Diabetes. Up to 80% of the Discovery Health Rate if not registered on the Scheme's Disease Management Programme. Basket of care as set by the Scheme.

Cardiovascular Disease Management for members registered on the Scheme's Disease Management Programme Basis of cover is contained in Annexure 7. Up to 100% of the Discovery Health Rate for services covered in the Scheme's basket of care if referred by the Scheme's DSP and enrolled on the Scheme's Disease Management Programme for Cardiovascular disease. Up to 80% of the Discovery Health Rate if not registered on the Scheme's Disease Management Programme. Basket of care as set by the Scheme.

Disease Management for cardio-metabolic risk syndrome for members registered on the Scheme's Disease Management Programme Up to a maximum of 100% of the Discovery Health Rate. Subject to authorisation and/or approval and the treatment meeting the Scheme's clinical entry criteria, treatment guidelines and protocols. Basket of care as set by the Scheme.

Disease Management for insomnia and obstructive sleep apnoea Up to a maximum of 100% of the Discovery Health Rate following completion of a validated sleep assessment. Subject to meeting the Scheme's clinical entry criteria, treatment guidelines and protocols. Basket of care as set by the Scheme.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Severe dental and oral procedures in Annexure 3 Up to a maximum of 100% of the Discovery Health Rate. Subject to the treatment meeting the Scheme's treatment guidelines and managed care criteria. Unlimited

Not covered. Dentistry No cover. Not applicable

Emergency Medical Services within the borders of South Africa. Up to a maximum of 100% of the Discovery Health Rate. Inter-hospital transfer subject to pre-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. Consultations in excess of the annual limit or those not meeting the Scheme's clinical entry criteria paid by the member. 1 consultation per person per year.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Out-of-hospital healthcare services related to pregnancy and delivery: antenatal classes and/or postnatal visits with a registered nurse; antenatal consultations with a network GP, gynaecologist or midwife; prenatal screening or Non-Invasive Prenatal Testing (NIPT) or defined chromosome testing; pregnancy scans; a defined basket of pregnancy blood tests; postnatal consultation with a network GP, gynaecologist or midwife for complications post delivery; dietician nutrition assessment; mental health consultation with a network GP, psychologist or counsellor; paediatrician, ENT or GP consultations for infants. Up to 100% of the Discovery Health Rate, or agreed rate. Only for a gynaecologist who practices within the KeyCare network within the selected network hospitals. 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 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.

Disease Management Programme to reduce the risks of depression for at-risk members Up to a maximum of 100% of the Discovery Health Rate at a network psychologist or Premier Plus network GP, following completion of the mental wellbeing assessment. Subject to meeting the Scheme's clinical entry criteria, treatment guidelines and protocols. Basket of care as set by the Scheme.

Disease Management for major depression for members registered on the Scheme's Disease Management Programme In addition to the cover contained in Annexure 7 up to 100% of the Discovery Health Rate for services covered in the Scheme's basket of care if referred by the Scheme's DSP. Beneficiary must be enrolled on this programme for cover of up to 100% of the Discovery Health Rate for psychotherapy sessions as part of their Prescribed Minimum Benefits. Basket of care as set by the Scheme.

Management of mental health disorders Up to a maximum of 100% of the Discovery Health Rate for out-of-hospital consultations, subject to registration on the Scheme's Disease Management Programme for Mental Health. Up to 80% of the Discovery Health Rate if not registered on the Scheme's Disease Management Programme. Up to 15 out-of-hospital consultations, for conditions as defined in Annexure A of the Regulations.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Not covered. Not a KeyCare Core scheme benefit. Table C (out-of-hospital benefit) covers specialists only (R5 750 per person per year); KeyCare Core provides no out-of-hospital day-to-day cover for this category.

Where MRI and CT scan is unrelated to the admission it will be covered from the Specialist Benefit subject to the Specialist Benefit limit of R5 750 per person per year. Subject to the treatment meeting the Scheme's treatment guidelines and managed care criteria.

Specialists KeyCare DPA Specialists: Up to a maximum of 100% of the KeyCare Direct Payment Arrangement Rate. Other Specialists who work within the network hospitals - Up to the Discovery Health Rate. Radiology and pathology services referred as part of the specialist visit up to 100% of the Discovery Health Rate, subject to the overall annual specialist benefit limit. Member must be referred by a GP. Subject to authorisation and/or approval and treatment meeting the Scheme's treatment guidelines and entry criteria. R5 750 per person per year.

Specialists KeyCare Specialists: Up to a maximum of 100% of the KeyCare Direct Payment Arrangement Rate. Other Specialists who work within the network hospitals: Up to a maximum of 100% of the Discovery Health Rate. Member must be referred by a GP. Unlimited

Gastroscopies, colonoscopies, proctoscopies and sigmoidoscopies Save for cover as contained in Annexure 8, or where indicated and approved for dyspepsia or children aged 12 years and under, subject to PMBs and use of the Scheme's network provider as contained in Annexure 9. Up to 100% of the Discovery Health Rate from Health Care Cover if done in the doctor's rooms and subject to authorisation. Unlimited

Conservative treatment for dyspepsia Up to a maximum of 100% of the Discovery Health Rate. Subject to authorisation and/or approval and the treatment meeting the Scheme's clinical entry criteria, treatment guidelines and protocols. Basket of care as set by the Scheme.

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, Severe anaphylactic reaction, Poisoning, Crime-related injury, Severe burns, External and internal head injuries, Loss of limb. Healthcare services related to Trauma benefit services covered under this benefit include: Allied healthcare services, External medical items, Hearing aids, Prescribed Medicine. Up to a maximum of 100% of the Discovery Health Rate. Paid from Health Care Cover and is subject to applicable limits. Excludes OTC medicines (inclusive of schedule 0, 1 and 2 drugs whether prescribed or not), optometry, antenatal classes and dentistry (other than severe dental and oral procedures contemplated in Annexure 3). Cover applies to 31 December of the following year after the trauma related injury occurred. Services: 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; Allied and therapeutic healthcare services (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 counselling sessions per beneficiary 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.

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. Subject to meeting the Scheme's clinical entry criteria. Unlimited

Defined diabetes and cholesterol screening tests Up to a maximum of 100% of the Discovery Health Rate for test code. Subject to meeting the Scheme's clinical entry criteria. Note: Consultation paid from available day-to-day benefits as defined in Table C, or by the member where no benefits are available. Where the consultation relates to a PMB the consultation will be paid from Health Care Cover. 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 payable by the member. 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. Subject to meeting the Scheme's clinical entry criteria, treatment guidelines and protocols. Once off BRCA testing and colonoscopy. Basket of care as set by the Scheme.

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. Subject to meeting the Scheme's clinical entry criteria. 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. Subject to meeting the Scheme's clinical entry criteria. Unlimited

Additional screening assessment or consultation Up to a maximum 100% of the Discovery Health Rate at an accredited network provider. Subject to meeting the Scheme's clinical entry criteria and treatment guidelines. One consultation per person per year.

Preventative Benefit - Pneumococcal vaccination Up to a maximum of 100% of the Discovery Health Medication Rate for the vaccination. Subject to the Scheme's protocols and clinical entry criteria. Note: Pneumococcal vaccines in excess of the limit, consultation and other healthcare services to administer the vaccine, paid by the member. Up to 2 pneumococcal vaccine doses per person per lifetime.

Preventative Benefit - Seasonal Influenza Vaccination Up to a maximum of 100% of the Discovery Health Medication Rate for the vaccination. Seasonal flu vaccines in excess of annual limit is payable by the member. Subject to Scheme protocols and clinical entry criteria. One seasonal influenza vaccine per person per year.