Discovery KeyCare Start

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.

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.

Cataract surgery: A R6 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.

Not covered. On KeyCare Start Regional, where members have elected the network arrangement for the purposes of attaining a discounted premium, the beneficiary shall be liable in respect of the cost of health care services obtained at private facilities which are not a designated service provider. This will not apply in the case of emergency services. Such service may be attained at any private facility.

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

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.

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.

Hospitalisation in chosen KeyCare Start network hospital: 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.

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. Up to a maximum of 100% for the Discovery Health Rate for related accounts. 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.

Procedures performed in the Short Stay Surgical Care Network: Up to a maximum of 100% of the Discovery Health Rate at a network provider for clinically appropriate low acuity surgical procedures. Up to a maximum of 100% for the Discovery Health Rate for related accounts. Subject to authorisation and/or approval and the treatment meeting the Scheme's clinical entry criteria, treatment guidelines and protocols. Related post-operative basket of care as set by the Scheme.

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

Cardiac stents and balloons: Up to a maximum of 100% of the Discovery Health Rate in the chosen KeyCare Start network hospital. Subject to authorisation and the treatment meeting the Scheme's treatment guidelines and clinical criteria. The device accumulates to the limit. The balance of the hospital and related accounts do not accumulate to the annual limit. Network supplier: Unlimited if supplied by the Scheme's network provider. Non-network supplier: 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.

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: Basis of cover contained in Annexure 7. 21 days in-hospital treatment per person per year.

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 in the chosen KeyCare Start network hospital. 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 R2 850 per person per year. Subject to the treatment meeting the Scheme's treatment guidelines and managed care criteria. Scan must be performed by a specialist at the chosen network hospital.

Chronic dialysis: Cover in a public facility according to the PMB, subject to Regulation 8 (3).

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. 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.

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.

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. Unlimited. Subject to the Scheme's preferred provider, protocols and clinical entry criteria.

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 Rule 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.

Organ transplant — Cover in a public facility according to the PMB, subject to Regulation 8 (3).

Acute medication: Up to a maximum of 100% of the Discovery Health Medication Rate only if prescribed and dispensed by nominated GP, or the Scheme's network providers. Subject to the Discovery KeyCare acute medicine formulary and protocols.

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.

Not covered. Mobility Devices: wheelchairs, long leg callipers and crutches: No cover. Subject to PMBs.

Other providers: Up to a maximum of 100% of the Discovery Health Rate in the chosen KeyCare Start network hospital.

Medication for the chronic Prescribed Minimum Benefit condition: Save for medication contemplated in Rule 15.18 of the Main Body of the Rules, basis of cover contained in Annexure 7. Subject to Scheme, 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.

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.

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.

Severe dental and oral procedures covered in Annexure 3: Up to a maximum of 100% of the Discovery Health Rate in the chosen KeyCare Start network hospital. Subject to the treatment meeting the Scheme's treatment guidelines and managed care criteria.

Not covered. Dentistry: Not applicable.

Dentistry: Up to a maximum of 100% of the Discovery Health Rate. Only at KeyCare Start network dentist, subject to a list of codes. In-hospital excluded.

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.

GP, includes consultations and selected small procedures: Up to a maximum of 100% of the Discovery Health Rate, subject to selected consultation and procedure codes. Member has to select a primary care GP that is part of the Scheme's selected network on joining the plan. GP visits will only be covered at nominated KeyCare Start network GP or KeyCare Start Regional Network GP on KeyCare Start Regional. Member can elect to change his/her nominated GP twice per person per year.

On Keycare Start Regional, access to out-of-hospital GP health care services is enabled on referral by the virtual clinic of the designated service provider.

GP consultations after hours: Up to a maximum of 100% of the Discovery Health Rate at the Scheme's network providers. Unlimited only at the Scheme's network providers.

Nurse-led consultations with or without video call consultations with a General Practitioner (including GP consultation, acute medicines, radiology and pathology requested by a GP when referred): Up to a maximum of 100% of the Discovery Health Rate or Discovery Health medication rate - subject to a list of codes, at a network provider. Only acute medicines, radiology and pathology requested by a GP will be covered under this benefit. Subject to PMBs.

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. Subject to the Scheme's preferred provider (where applicable) and the treatment meeting the Scheme's clinical entry criteria, treatment guidelines and protocols. Consultations in excess of the annual limit or those not meeting the Scheme's clinical entry criteria paid by the member.

Out-of-hospital healthcare services related to pregnancy and delivery: Up to 100% of the Discovery Health Rate, or agreed rate. Subject to the treatment meeting the Scheme's treatment guidelines and protocols. Services: Antenatal and postnatal consultations with nominated GP, as stipulated in Table C; Antenatal classes and antenatal and postnatal consultations with a midwife; Specialist consultations as stipulated in Table C; Pregnancy scans: 2 per pregnancy and as stipulated in Table C; Blood tests: as stipulated in Table C.

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.

Optometry: Up to a maximum of 100% of the Discovery Health Rate. Only at KeyCare Start network optometrist and subject to Scheme protocol. One pair of single vision, bifocal or multifocal lenses with a basic frame or a basic set contact lenses per person every twenty-four months from their last date of service.

Radiology & Pathology: Up to a maximum of 100% of the Discovery Health Rate in the chosen KeyCare Start network hospital. 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.

Selected basic blood tests: Up to a maximum of 100% of the Discovery Health Rate. Only if requested by member's nominated GP, subject to list of procedure codes and PMBs. 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 in the chosen KeyCare Start network hospital.

Selected basic x-rays and ultrasounds at the Scheme's network providers: Up to a maximum of 100% of the Discovery Health Rate at the Scheme's network providers. Only if requested by member's nominated GP, subject to list of procedure codes and PMBs.

MRI and CT Scans: Up to a maximum of 100% of Discovery Health Rate at the Scheme's network providers. Subject to the treatment meeting the Scheme's treatment guidelines and managed care criteria. Member must be referred by nominated GP. Accumulates to the Specialist Benefit limit of R2 850 per person per year.

Specialists KeyCare Start: Specialists contracted to the chosen KeyCare Start network hospital: Up to a maximum of 100% of the Discovery Health Rate. Other Specialists who work within the chosen KeyCare Start network hospitals: Up to a maximum of 100% of the Discovery Health Rate. Member must be referred by nominated GP.

Specialists: Member must be referred by nominated GP. Subject to authorisation and/or approval and treatment meeting the Scheme's treatment guidelines and entry criteria. KeyCare Start and KeyCare Start Regional DPA Specialists: Up to a maximum of 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. Other Specialists who work within the network hospitals: Up to a maximum of 100% of the Discovery Health Rate. 2 visits up to a maximum of R2 850 per person per year.

Gastroscopies, colonoscopies, proctoscopies and sigmoidoscopies: Save for cover as contained in Annexure 8, or where indicated and approved for dyspepsia or for children aged 12 years and under, subject to PMBs in a defined list of network facilities 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. Subject to authorisation and/or approval and the treatment meeting the Scheme's clinical entry criteria, treatment guidelines and protocols.

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.

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.

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. 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 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. Cover is not restricted to the Scheme's DSPs as stipulated in Annexure 7. Services limits: External Medical Items limited to R28 900 per family per year, except for prosthetic limbs limited to 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, plus up to 6 additional 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.

Not covered. 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).

Not covered. Hearing aids: Limited to R17 850 per family per year

Not covered. Allied and therapeutic healthcare services including: … physiotherapists … only funded within the Trauma benefit.

Not covered. Allied and therapeutic healthcare services including: acousticians, biokineticists, chiropractors, dieticians, homeopaths … only funded within the Trauma benefit.

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

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.

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. Subject to meeting the Scheme's clinical entry criteria. Tests in excess of annual limit payable by the member. Appropriate HIV screening tests - 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.

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.

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.

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

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. Note: Consultation and other healthcare services to administer the vaccine, paid from available day-to-day benefits as defined in Table C, or by the member where no benefits are available.