Saver Health Plan Guide 2015

DeltaEssential CoastalClassic

SAVER SERIES

Good health can change the world

HEALTH PLAN GUIDE 2015

THE DISCOVERY HEALTH MEDICAL SCHEME: YOUR BEST CHOICE

The Discovery Health Medical Scheme is South Africas largest and most stable medical scheme by far, with over 2.6 million members, the widest plan range, over R11 billion in reserves, and the highest possible credit rating (AA+) for our ability to pay

your claims. Our rich benefits, competitive contributions and great

service have resulted in us being voted SAs most loved medical aid by members, doctors, employers and financial advisers.

5 REASONS WHYIS THE BEST CHOICE FOR YOUTHE DISCOVERY HEALTH MEDICAL SCHEME

Cont

ributi

ons

Market

The benefits explained in this brochure are provided by the Discovery Health Medical Scheme, registration number 1125, administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. This brochure is only a summary of the key benefits and features of the Discovery Health Medical Scheme plans, awaiting formal approval from the Council for Medical Schemes. When reference is made to we in the context of benefits, members, payments of cover, in this brochure this is a reference to the Discovery Health Medical Scheme. Vitality is not part of the Discovery Health Medical Scheme. Vitality is a seperate product sold and administered by Discovery Vitality (Pty) Ltd. Registration number 1999/007736/07, an authorised financial provider.

THE LOWEST CONTRIBUTIONS

One of the benefits of the Discovery Health Medical Scheme is our ability to contain healthcare costs and pass these savings on to you. On a like-for-like basis, Discovery Health Medical Scheme plan contributions are as much as 14% lower than those of any other South African medical scheme.

1 14%LOWER

THE RICHEST BENEFITS AND FEATURES LIKE FULL COVER WITHIN OUR NETWORKS

You will always enjoy full cover and avoid co-payments when visiting a specialist or GP who we have a payment arrangement with, when getting medicine on our day-to-day preferred medicine list from one of the 2000 pharmacies in our pharmacy network, or when using hospitals in our network. We even cover a range of preventive tests from cholesterol to HIV screening without you having to use the money in your Medical Savings Account.

Vitality is not part of the Discovery Health Medical Scheme. Vitality is a separate product sold and administered by Discovery Vitality (Pty) Ltd. Registration number 1999/007736/07, an authorised financial services provider.

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ADDITIONAL BENEFITS THAT ENHANCE YOUR COVER

You get access to unique benefits that enhance your cover such as access to: Second opinion services from Cleveland Clinic for life-threatening and life-changing conditions Cover for a defined list of the latest treatments not available in South Africa through the Specialised Medicine and Technology

Benefit Emergency medical cover when travelling abroad or emergency medical evacuations from certain sub-Saharan African countries.

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FULL COVER CHOI

CE

FULL

COVER CHOICE

VITALITY: GET HEALTHY. GET REWARDED.

By being a Discovery Health Medical Scheme member, you have the opportunity to join Vitality, the worlds leading science-based wellness programme that encourages you to get healthier, and gives you fantastic rewards.

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OUR TECHNOLOGY UNLOCKS THE BEST OF CARE

Our Discovery app and our website have both been purpose-built to help you get the most out of your health plan.

Discovery HealthID, our award-winning app for doctors, allows your doctor to digitally access your health record and write electronic prescriptions, all with the touch of a finger, after you have given permission.

Our online booking facility and virtual consultations allow you to conveniently connect with your doctor.

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2THE DISCOVERY HEALTH MEDICAL SCHEME PLAN RANGE

Unlimited cover in any private hospital Guaranteed full cover in hospital for

specialists on a payment arrangement, and up to 200% of the Discovery Health Rate on the Classic Plan and 100% on the Essential Plan for other healthcare professionals

Full cover for chronic medicine for all Chronic Disease List conditions

A savings account and limited Above Threshold Benefit for your day-to-day healthcare needs

Additional cover when your Medical Savings Account runs out for GP consultation fees, blood tests, maternity costs and some durable external medical items

Cover for medical emergencies when travelling

Unlimited private hospital cover Guaranteed full cover in hospital for specialists

on a payment arrangement, and up to 200% of the Discovery Health Rate on Classic Plans and 100% on Essential Plans for other healthcare professionals

Full cover for chronic medicine for all Chronic Disease List conditions plus some additional chronic conditions

A high savings account as well as unlimited Above Threshold Benefit for your day-to-day healthcare needs

Additional cover when your Medical Savings Account runs out for GP consultation fees, preferred medicine, blood tests, maternity costs and some durable external medical items

Access to specialised, advanced medical care in SA and abroad


Unlimited cover in any private hospital, including private ward cover

Guaranteed full cover in hospital for specialists on a payment arrangement, and up to 300% of the Discovery Health Rate for other specialists

Full cover for chronic medicine for all Chronic Disease List conditions plus some additional chronic conditions; plus access to an exclusive list of brand medicines

The highest savings account and unlimited Above Threshold Benefit for your day-to-day healthcare needs

Additional cover when your Medical Savings Account runs out for GP consultation fees, preferred medicine, blood tests, maternity costs and some durable external medical items

Access to specialised, advanced medical care in SA and abroad


EXECUTIVE PLAN PRIORITY SERIESCLASSIC | ESSENTIAL

COMPREHENSIVE SERIESCLASSIC | ESSENTIAL | DELTA

CLASSIC | ESSENTIAL | DELTA | COASTAL

3 Unlimited private hospital cover Guaranteed full cover in hospital for

specialists on a payment arrangement, and up to 200% of the Discovery Health Rate on Classic Plans and 100% on Essential and Coastal Plans for other healthcare professionals

Full cover for chronic medicine for Chronic Disease List conditions

A savings account for your day-to-day healthcare needs

Additional cover when your Medical Savings Account runs out for GP consultation fees and maternity costs


Unlimited private hospital cover Guaranteed full cover in hospital for

specialists on a payment arrangement, and up to 200% of the Discovery Health Rate on Classic Plans and 100% on Essential and Coastal Plans for other healthcare professionals

Full cover for chronic medicine for Chronic Disease List conditions when you use MedXpress


Unlimited hospital cover in the KeyCare network of hospitals

Guaranteed full cover in hospital for specialists in the KeyCare network, and up to 100% of the Discovery Health Rate for other healthcare professionals

Essential cover for chronic medicine on our medicine list for Chronic Disease List conditions

Unlimited cover for medically appropriate GP consultations, blood tests, x-rays or medicine in our KeyCare network on the KeyCare Plus and KeyCare Access Plans

SAVER SERIESCLASSIC | ESSENTIAL | DELTA | COASTAL

CORE SERIES KEYCARE SERIESCLASSIC | CLASSIC DELTA | ESSENTIAL | ESSENTIAL DELTA | COASTAL PLUS | ACCESS | CORE

SAVER SERIESCLASSIC | ESSENTIAL | DELTA | COASTAL

Vitality is not part of the Discovery Health Medical Scheme. Vitality is a separate product sold and administered by Discovery Vitality (Pty) Ltd.

Registration number 1999/007736/07, an authorised financial services provider.

4SAVER SERIES

PRODUCT PLATFORM

THE DISCOVERY HEALTH MEDICAL SCHEME OFFERS A RANGE OF OPTIONS TO CATER FOR EVERY NEED THE SAVER SERIES OFFERS AFFORDABLE COVER FOR HOSPITAL, CHRONIC CONDITIONS AND DAY-TO-DAY MEDICAL EXPENSES

Discovery Vitality offers the worlds leading science-based programme with a personalised approach to wellness

Vitality helps you get healthier by giving you the knowledge, tools and motivation to improve your health its been clinically proven that Vitality members are healthier, live longer and have lower healthcare costs.

We pay your day-to-day medical expenses from your Medical Savings Account. Any unused funds are carried over to the next year unlike traditional plans where unused cover is lost.

YOUR MEDICAL SAVINGS ACCOUNT

We extend your day-to-day cover through the Insured Network Benefit. When you have spent your annual Medical Savings Account allocation, we cover services such as GP consultation fees and maternity costs from a provider in our network. Cover depends on the health plan you choose.

THE INSURED NETWORK BENEFIT EXTENDS YOUR DAY-TO-DAY COVER

FOR ESSENTIAL HEALTHCARE SERVICES

HOSPITAL COVER

There is no overall limit for hospital cover on the Saver Series. On Classical and Essential, you can go to any private hospital and on Delta and Coastal you must go to our network of hospitals for the Delta options and the Coastal Plan. If you use a specialist who we have a payment arrangement with, we cover you in full for your approved procedure in hospital.

CHRONIC ILLNESS COVER

We pay approved chronic medicines that are on the Schemes medicine list in full, or up to a set monthly rand amount for medicines not on the medicine list when you use MedXpress.

SCREENING AND PREVENTION

The Screening and Prevention Benefit covers blood glucose, blood pressure, cholesterol and body mass index measurements at a Discovery Wellness Network provider. The benefit also pays for a mammogram, Pap smear, PSA (prostate screening test) and HIV screening tests. If you are 65 years or older or are registered for certain chronic conditions, we also cover a seasonal flu vaccine.


5THE GUARANTEE OF FULL COVER

OUR EXTENSIVE NETWORKS OF HEALTHCARE PROVIDERS, COMBINED WITH OUR UNIQUE SELF-SERVICE TOOLS MEAN YOU CAN AVOID CO-PAYMENTS. THESE TIPS WILL GUIDE YOU TO FULL COVER

On the Delta options you are covered in full when you use a network hospital. On the Coastal Plan, you must go to a hospital in one of our four coastal provinces for planned admissions. Use our online MaPS tool to find a hospital in these networks.

USE OUR EXTENSIVE HOSPITAL NETWORKS

1

Hospital

Chronic cover

Day-to-day

Doct

or

We offer a comprehensive list of medicine which we cover in full. Use Discovery MedXpress to order medicine for home delivery or express collection at selected pharmacies. Alternatively ask your pharmacist about your options to avoid a co-payment.

USE OUR PREFERRED MEDICINE

2USE A GP OR SPECIALIST WHO WE HAVE A PAYMENT ARRANGEMENT WITH

We offer the broadest range of GP and specialist payment arrangements, which provides full cover both in and out of hospital. Over 90% of our member interactions are with a GP or specialist in our payment arrangements. Use our MaPS tool to find a healthcare professional who we have an arrangement with.

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USE A NETWORK PROVIDER TO ACCESS THE INSURED NETWORK BENEFIT4The Saver Series has a Medical Savings Account which empowers you to make informed decisions on how to spend on your day-to-day healthcare expenses. Once you have spent your annual Medical Savings Account allocation, we extend your day-to-day cover through the Insured Network Benefit. You have cover for unlimited GP consultation fees and maternity costs. Cover for these healthcare services depends on the health plan you choose. Use our online MaPS tool to find a network provider.

6SAVER SERIES


Unlimited private hospital cover

Guaranteed full cover in hospital for specialists on a payment arrangement, and up to 200% of the Discovery Health Rate on Classic Plans and up to 100% of the Discovery Health Rate on Essential and Coastal Plans for other healthcare professionals

Full cover for chronic medicine for all Chronic Disease List conditions

A savings account for your day-to-day healthcare needs

FULL COVER CH

OICE

Additional cover when your Medical Savings Account runs out for GP consultation fees and maternity costs


KEY FEATURES

BENEFITS AVAILABLE ON THE SAVER SERIES

Classic Classic Delta Essential Essential Delta Coastal

Hospital cover

Hospital Network Any private hospital Private hospitals in the Delta network

Any private hospital Private hospitals in the Delta network

Private hospitals in the four coastal provinces

Cover for healthcare professionals in hospital

200% of the Discovery Health Rate for specialists, GPs and other healthcare professional services

100% of the Discovery Health Rate for specialists, GPs and other healthcare professional services

Day-to-day benefits

Insured Network Benefit

Extended day-to-day cover when your Medical Savings Account allocation has run out for:

Limited GP consultations

Limited antenatal consultations and two 2D pregnancy scans at network providers

Limited GP consultations

Medical Savings Account Your MSA allocation is 25% of your monthly contributions

Your MSA allocation is 15% of your monthly contributions

Your MSA allocation is 25% of your monthly contributions

Chronic benefits

Designated network for chronic medicines

You have cover for approved chronic medicine in our network of 2 000 pharmacies. If you use a pharmacy outside of this network, you may have a co-payment on the dispensing fee charged by the pharmacist

You have cover for approved chronic medicine, if you use MedXpress. If you dont use MedXpress a 20% co-payment applies


You have cover for approved chronic medicine, if you use MedXpress. If you dont use MedXpress a 20% co-payment applies


THE HEALTH PLANS ARE:

Classic

Classic Delta

Essential

Essential Delta

Coastal

There are slight differences in benefits as indicated below. The benefits not mentioned in the table are the same across all five options.

THE SAVER SERIES HAS FIVE HEALTH PLAN OPTIONS

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8SAVER SERIES

HOSPITAL COVER

WE COVER YOU IN HOSPITAL FOR EMERGENCY AND PLANNED HOSPITAL ADMISSIONS. THERE IS NO OVERALL LIMIT FOR HOSPITAL COVER

Your Hospital Cover is made up of:

Cover for the account from the hospital

Cover for the accounts from your admitting doctor, anaesthetist or any other approved healthcare professional.

Cover for your hospital account

We cover you in any private hospitals for emergency and preauthorised hospital admissions. We cover your hospital account (the ward and theatre fees) at the rate agreed with the hospital. You have unlimited cover for general wards.

Network hospitals on Delta and Coastal

On Classic Delta and Essential Delta, you are covered in full at private hospitals and day clinics in the Delta Hospital Network. For planned admissions at hospitals outside the network, you must pay an amount of R5 950 upfront to the hospital. This does not apply in an emergency.

On the Coastal Plan, you must go to a hospital in one of the four coastal provinces for a planned hospital admission. If you dont use a coastal hospital, we pay up to a maximum of 70% of the hospital account and you pay the differences.

Investigations are covered differently

Cover for scopes (gastroscopies, colonoscopies, sigmoidoscopies and proctoscopies)

We pay the first R3 400 of your hospital account from your available day-to-day benefits. We pay the balance of the hospital account and your related accounts from your Hospital Benefit.

Cover for related accountsWe guarantee full cover when you use healthcare professionals who we have a payment arrangement with. If you are on a Classic Plan you benefit from access to the broadest range of specialists, which represents over 90% of our members specialist interactions.

On the Classic Plans we cover specialists who we dont have a payment arrangement with and other healthcare professionals up to 200% of the Discovery Health Rate.

On the Essential and Coastal Plans we cover specialists who we dont have a payment arrangement with and other healthcare professionals up to 100% of the Discovery Health Rate.

Radiology and pathology are covered up to 100% of the Discovery Health Rate on all plans.

9Severe dental and oral surgery The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with no upfront payment and no overall limit. This benefit is subject to authorisation and the Schemes clinical rules.

Other dental treatment in hospitalYou need to pay a portion of your hospital or day clinic account upfront for dental admissions. This amount varies, depending on your age and the place of treatment:

We pay the balance of the hospital account from your Hospital Benefit, up to 100% of the Discovery Health Rate. We pay the related accounts, which include the dental surgeons account, from your Hospital Benefit, up to 100% of the Discovery Health Rate. On Classic Plans, we pay anaesthetists up to 200% of the Discovery Health Rate.

For beneficiaries 13 and older, we cover routine, conservative dentistry, such as preventive treatments, simple fillings and root canal treatments from your available day-to-day benefits.

No overall dental limit

There is no overall limit for dental treatment. However, all dental appliances, their placement, and orthodontic treatment (including related accounts for orthognathic surgery) are paid at 100% of the Discovery Health Rate from your Medical Savings Account, as long as you have money available.

HOSPITAL COVER

Cover for MRI and CT scansIf your MRI or CT scan is done as part of an approved hospital admission, we pay for it from your Hospital Benefit at 100% of the Discovery Health Rate.

If you are admitted for conservative back or neck treatment, or if the scan is not related to your hospital admission, we pay the first R2 600 of the amount for the scan from your available day-to-day benefits. We pay the balance of the scan from your Hospital Benefit, up to 100% of the Discovery Health Rate. Specific rules and limits apply to conservative back and neck scans.

COVER FOR DENTAL TREATMENT

YOUNGER THAN 13 R80013 and older R2 850

Day clinic

Hospital

YOUNGER THAN 13 R1 70013 and older R4 400

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SAVER SERIES

SOME IN-HOSPITAL HEALTHCARE SERVICES HAVE AN ANNUAL LIMIT

Cochlear implants, auditory brain implants & processorsR187 000 for each person for each benefit

Internal nerve stimulatorsR129 000 for each person

Hip, knee and shoulder joint prosthesesThere is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R36 400 applies to each prosthesis

Prosthetic devices used in spinal surgeryR25 500 for the first level, R51 000 for two or more levels, limited to one procedure for each person

Mental health21 days for each person

Alcohol and drug rehabilitation21 days for each person

Compassionate careR44 000 for each person in their lifetime

Chronic dialysisWe cover these expenses in full if we have approved your treatment plan and you use a provider in our network. If you go elsewhere you have to make a co-payment

HOSPITAL COVER

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DISCOVERY HOMECARE

Discovery HomeCare is a unique home-based service that offers you quality care in the comfort of your own home. HomeCare allows you, as a Discovery Health Medical Scheme member, to continue to recover in a familiar environment, and with minimum disruption to your normal routine and family life whilst maximising your time at home with your loved ones.

Healthcare services offered

We offer quality nursing and care worker support for these therapeutic areas: Post-natal care

End of life, palliative care delivered in partnership with the Hospice Palliative Care Association of South Africa

Home IV infusions of antimicrobials, biologics, IV iron and immunoglobulins for stable patients

Wound care of venous ulcers, diabetic foot ulcers, pressure sores and other moderate to severe wounds for stable patients

Respite care short-term care services that offer temporary relief for caregivers looking after the healthcare needs of beneficiaries

How to use Discovery HomeCareThis service is subject to existing benefits, and will be offered in 2015 to members living in Gauteng. Respite care will be for your own account, as these services are not covered by the Scheme.

You can speak to your doctor to discuss your options.

DISCOVERY HOMECARE UNIQUE HOME-BASED SERVICES

DIS

COVER

Y HOMECARE

DISCOVERY HOMECA

RE

CHRONIC ILLNESS, CANCER AND HIV COVER

Cover for chronic conditions

You have extensive cover for an essential list of chronic conditions. We need to approve your application before we cover your condition from the Chronic Illness Benefit.

If you are registered on the Chronic Illness Benefit for diabetes and a defined list of heart-related conditions you can access our Personal Health Programmes to help better manage your condition.

Medicine cover for the Chronic Disease ListYou have full cover for approved medicine on our medicine list. If you use medicine that is not on the medicine list, you can use up to a set monthly amount for each class of medicine.

How we pay for medicineWe pay for medicine up to a maximum of the Discovery Health Rate for medicines. The Discovery Health Rate for medicines is the price of medicine as well as a fee for dispensing it. The Discovery Health Health Medical Scheme has negotiated contracts with over 2 000 pharmacies, who have agreed to charge no more than this rate. If you use a pharmacy out of this network, you may have a co-payment on the dispensing fee charged by the pharmacist.

Designated Service Provider for Delta

On Classic Delta and Essential Delta, your Designated Service Provider for chronic medicine is MedXpress. If you dont use MedXpress a 20% co-payment applies.

Cover for diabetesIf you are registered on the Chronic Illness Benefit for diabetes. We cover approved bluetooth-enabled glucose monitoring devices and test strips that help you and your doctor with real time

management of your condition.

Cover for cancerIf youre diagnosed with cancer, we cover you from the DiscoveryCare Oncology Programme once we have approved your cancer treatment. We do not limit your cancer treatment costs. We cover the first R200 000 of your approved cancer treatment over a 12-month cycle in full. If your treatment costs more than R200 000, you will need to pay 20% of the additional costs. Cancer treatment that is a Prescribed Minimum Benefit is always covered in full.

All cancer-related healthcare services are covered up to 100% of the Discovery Health Rate. You might have a co-payment if your healthcare professional charges above this rate.

Cover for HIV and AIDSWhen you register for our HIVCare Programme you are covered for the all-inclusive care that you need. You get access to clinically sound and cost-effective treatment and you can be assured of confidentiality at all times. Approved medicines on our medicine list are covered in full. Medicines not on our list are covered up to a set monthly amount. You will need to get your medicine from a Designated Service Provider to avoid a 20% co-payment.

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SAVER SERIES

DELIVERING MEDICINE WHEREVER YOU ARE

What Discovery MedXpress offers you

Convenience Delivery to your door theres no need to wait in queues or leave home to get your medicine.

A simple process there are no complicated forms to complete. All we need is a valid script and a phone call.

Regular updates well keep you up to date on any changes that may affect your cover for chronic medicine when you call us to order your medicine.

Advice to help you save

When using MedXpress, Discovery Healths qualified service agents can also advise you on the most cost-effective alternatives. And you will always be charged at the Discovery Health Rate for medicines or less in effect getting rid of all those small co-payments that add up over time.

Important points to rememberDelivery of your medicine Chronic or repeatable prescription medicine will be delivered to your preferred address

anywhere in South Africa.

Once-off prescription medicine delivery orders are currently only available in the Johannesburg, Pretoria and Cape Town metropolitan areas.

Collect your medicine Send a photo of your prescription through MedXpress and collect your medicine

from one of our partner pharmacies. Your medicine will be ready for collection at a designated counter. Please remember to bring your original prescription when you collect your medicine.

How you can order medicine Clearly mark your prescription with the word MedXpress and your membership number, and email your prescription to [email protected] or fax it to 011 539 1020, or you can call us on 0860 99 88 77.

There is no additional administration or delivery cost, so you can take back the time spent in the pharmacy by placing your order now.

MEDXPRESS MEDICINE DELIVERED TO YOUR DOOR

MedXpress lets you order medicine online or over the phone and have it delivered directly to your door. In 2015, you will have the option to collect your prescription medicine from selected pharmacies.

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SAVER SERIES

MANAGING YOUR CHRONIC CONDITION THROUGH OUR PERSONAL HEALTH PROGRAMMES

Our Personal Health Programmes are a set of unique lifestyle programmes to assist you - with the help of your Premier Practice GP - to actively manage your chronic condition to make you healthier.

Any Discovery Health Medical Scheme member registered on the Chronic Illness Benefit for diabetes, hypertension, hyperlipidaemia or ischemic heart disease can join a Personal Health Programme.

You have the option to enrol on one of these programmes via our website or through your GP if they belong to the Discovery Health Premier Practice Network.

Your Premier Practice GP will prescribe a chronic disease management lifestyle programme for you.

Our Personal Health Programmes are based on clinical and lifestyle guidelines, and give you and your GP the tools to better monitor and manage your condition.

In addition, the programme unlocks valuable healthcare services such as dieticians and biokineticists that you may require as part of the programme.

How to join a Personal Health Programme

Speak to your GP or log onto www.discovery.co.za

Personal Health Programmes features to make you healthier:

The programme guides you on what to do to improve your health

Your Premier Practice GP is your dedicated partner on this journey and will monitor you throughout the programme

Premier Practice GPs are able to track and monitor your progress in real time by viewing your health metrics such as fitness and blood glucose levels, weight management, nutrition and medication intake

You can also monitor your own progress at any time, through relevant alerts and reminders

If you are a Vitality member, you will also earn points and unlock additional rewards to help you live well

Personal Health Programmes are brought to you by Discovery Vitality (Pty) Ltd, registration number 1999/007736/07 and Discovery Health (Pty) Ltd, registration number 1997/013480/07. Authorised financial services providers.

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MANAGING YOUR CHRONIC CONDITION THROUGH OUR PERSONAL HEALTH PROGRAMMES

HealthID is the first electronic health record application of its kind in South Africa. It puts all your health records in your doctors hands so you wont have to try and remember everything. It also assists your doctor in interacting with us.

Access your medical history and electronic health records Your doctor can go into your electronic health record and access your health information to see your medical history. So, if you are having trouble remembering particular medicines youve taken, this information is available to your doctor immediately. Also, you can save time and money by not having to repeat tests and investigations, because the results of your previous tests are available for your doctor to see.

Apply for chronic coverIf you are diagnosed with a chronic condition, your doctor can complete an electronic Chronic Illness Benefit application using HealthID. This application is easy and convenient, because your doctor gets the information they need for your specific condition when completing the application and you can get immediate approval for certain conditions.

Write electronic scriptsDuring your consultation, your doctor can prescribe medicine for you using electronic scripting. You can find ways to reduce or even avoid co-payments on your medicines before you even reach the pharmacy because your doctor can also see medicines on our approved medicine list, as well as the cost of those medicines, before finalising your prescription.

View your benefit informationYour doctor also has instant access to your health benefit information to help you get the most out of your benefits. All these functions are designed to make your visit to your doctor easier and more productive.

With Discoverys HealthID app doctors can:

HealthID is brought to you by Discovery Health (Pty) Ltd. Registration number 1997/013480/07, an authorised financial services provider.

Give your doctor consent To benefit from HealthID, your doctor will need your permission to access your health records. You will need to give consent to each doctor you visit before that doctor can access your health records on HealthID. You can log onto www.discovery.co.za to give your consent.

No unauthorised person will have access to your personal medical information.

HEALTHID YOUR MEDICAL INFORMATION IN YOUR DOCTORS HANDS

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SAVER SERIES

Your cover is made up of two elements:

Your Medical Savings Account

The Insured Network Benefit

We pay for day-to-day medical expenses like visits to healthcare professionals, radiology and pathology from your Medical Savings Account, as long as you have money available.

When you have spent your annual Medical Savings Account allocation, we extend your cover for essential healthcare services through the Insured Network Benefit, and you will need to pay for your other day-to-day expenses.

DAY-TO-DAY COVER

HOW WE COVER YOUR DAY-TO-DAY HEALTHCARE EXPENSES


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WHEN YOUR ANNUAL MSA ALLOCATION IS USED UP, YOU HAVE ACCESS TO A UNIQUE SET A HEALTHCARE SERVICES THAT ARE PAID IN FULL WHEN YOU USE A NETWORK PROVIDER. WE COVER:

Plan Single member

Family

Classic and Coastal

3 consultations 6 consultations

Essential 2 consultations 4 consultations

FULL COVER CHOI

CE

FULL

COVER CHOICE

INSURED NETWORK BENEFIT

On Classic and Classic Delta, you have access to eight antenatal consultations and two 2D pregnancy scans, provided you use a gynaecologist who we have a payment arrangement with.

We cover for your face-to-face and virtual GP consultations if you use a GP in the Discovery network up to:

ANTENATAL CONSULTATIONS GP CONSULTATIONS

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SAVER SERIESSAVER SERIES

ADDITIONAL BENEFITS THAT ENHANCE YOUR COVER

WE MAKE YOUR MEDICAL SAVINGS ACCOUNT LAST LONGER

Preventive screening The Screening and Prevention Benefit covers certain tests like blood glucose, blood pressure, cholesterol and body mass index when done at any one of the Discovery Wellness Network providers. We also cover a mammogram, Pap smear, PSA (a prostate screening test) and HIV screening tests. Members 65 years or older and members registered for certain chronic conditions are also covered for a seasonal flu vaccine.

Scopes We pay for scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) from your Hospital Benefit, if its done in your doctors rooms. We pay up to 200% of the Discovery Health Rate if you are on a Classic Plan and up to 100% of the Discovery Health Rate if you are on an Essential or Coastal Plan.

Claims related to traumatic events The Trauma Recovery Extender Benefit covers out-of-hospital claims related to certain traumatic events. Claims are paid from the Trauma Recovery Extender Benefit for the rest of the year in which the trauma occurred, as well as the year after the event occurred. You may need to apply for this benefit.

ACCESS TO DIGITAL CONVENIENCE

Online bookings and virtual consultations You can conveniently use our Discovery app to make real time online bookings and to connect with your doctor virtually. These virtual consultations are paid from your available day-to-day benefits.

TRAVEL AND EVACUATION COVER

International travel You have cover of up to R5 million for each person on each journey for emergency medical costs while you travel outside South Africa. This cover is for a period of 90 days from your departure from South Africa. Pre-existing conditions are excluded.

Africa evacuation cover You have cover for emergency medical evacuations from certain sub-Saharan African countries back to South Africa. Pre-existing conditions are excluded.

ACCESS TO THE MOST ADVANCED MEDICAL COVER

International second opinion servicesThrough your specialist you have access to online second opinion from Cleveland Clinic on life-threatening and lifechanging conditions. We cover 50% of the cost of the second opinion service.

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Classic Classic DeltaEssentialEssential DeltaCoastal

TOTAL CONTRIBUTIONS (INCLUDING MEDICAL SAVINGS ACCOUNT AMOUNTS)

* Wecountamaximumofthreechildrenwhenweworkoutthemonthlycontributions,annualMedicalSavingsAccount.** IfyoujointheSchemeafterJanuary,youwontgetthefullamountbecauseitiscalculatedbycountingtheremainingmonthsintheyear.

Annual Medical Savings Account amounts**

CONTRIBUTIONS

Main memberR2 172R1 734R1 725R1 378R1 710

AdultR1 710R1 368R1 294R1 036R1 282

Child*R869R697R690R552R688

Main memberR6 516R5 196R3 096R2 472R5 124

AdultR5 124R4 104R2 328R1 860R3 840

Child*R2 604R2 088R1 236R984R2 064

Classic Classic DeltaEssentialEssential DeltaCoastal

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SAVER SERIES

DELTA HOSPITAL NETWORK

APPLICABLE TO CLASSIC DELTA SAVER AND ESSENTIAL DELTA SAVER

You are covered in full at hospitals in the Delta Hospital Network. For planned admissions to any other private hospital, you must pay an upfront amount of R5 950. This does not apply in an emergency.

Please note that these lists are subject to change. Go to www.discovery.co.za for the latest list of hospitals.

Gauteng

Arwyp Medical Centre Life Bedford Gardens Hospital Netcare Bougainville Private Hospital Life Brenthurst Clinic Life Carstenhof Clinic Clinix Private Hospital Lesedi Clinix Private Hospital Sebokeng Clinton Clinic Genesis Clinic Mediclinic Emfuleni Netcare Femina Hospital Life Fourways Hospital Legae Private Hospital Lenmed Clinic Life Little Company of Mary Louis Pasteur Hospital Midvaal Private Hospital Mediclinic Morningside Life Robinson Private Hospital Life Roseacres Clinic Suikerbosrand Clinic The Donald Gordon Medical Centre Life Wilgeheuwel Hospital

Plus 49 day clinics

Free State Life Rosepark Hospital

Universitas Private Hospital

Horizon Eye Care Centre Plus 3 day clinics

KwaZulu-Natal

Life Chatsmed Garden Hospital

Life Entabeni Hospital

Ethekwini Hospital

Midlands Medical Centre

Life Westville Hospital

Plus 10 day clinics

Western Cape

Mediclinic Cape Town

Life Vincent Pallotti Hospital

Mitchells Plain Medical Centre

Mediclinic Panorama

Mediclinic Vergelegen

Plus 19 day clinics

Eastern Cape Life New Mercantile Hospital

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EXCLUSIONS

THE DISCOVERY HEALTH MEDICAL SCHEME HAS CERTAIN EXCLUSIONS. WE DO NOT PAY FOR HEALTHCARE SERVICES RELATED TO THE FOLLOWING, EXCEPT WHERE STIPULATED AS PART OF A DEFINED BENEFIT OR UNDER THE PRESCRIBED MINIMUM BENEFITS

General exclusion list

Cosmetic procedures and treatments

Otoplasty for bat ears, port-wine stains and blepharoplasty (eyelid surgery)

Breast reductions or enlargements and gynaecomastia

Obesity

Frail care

Infertility

Wilfully self-inflicted illness or injury

Alcohol, drug or solvent abuse

Wilful and material violation of the law

Wilful participation in war, terrorist activity, riot, civil commotion, rebellion or uprising

Injuries sustained or healthcare services arising during travel to or in a country at war

Experimental, unproven or unregistered treatments or practices

Search and rescue

Any costs for which a third party is legally responsible

We also do not cover the complications or the direct or indirect expenses that arise from any of the exclusions listed above, except where stipulated as part of a defined benefit or under the Prescribed Minimum Benefits.

Waiting periods

If we apply waiting periods because you have never belonged to a medical scheme or have had a break in membership of more than 90 days before joining the Discovery Health Medical Scheme, you may not have access to the Prescribed Minimum Benefits during your waiting periods. This includes cover for emergency admissions.

If you had a break in cover of less than 90 days before joining the Discovery Health Medical Scheme, you may have access to Prescribed Minimum Benefits during waiting periods.

In all instances, the Discovery Health Medical Scheme Rules prevail. Please consult the Scheme Rules on www.discovery.co.za

The benefits outlined in this guide are a summary of the plans registered in the Discovery Health Medical Scheme Rules. These benefits are reviewed annually and amended in line with the requirements of the Medical Schemes Act and also take into account the requirements of the Consumer Protection Act where it relates to the business of a medical scheme.

USE THESE HANDY DEFINITIONS TO HELP YOU UNDERSTAND IMPORTANT CONCEPTS DISCUSSED IN THIS GUIDE

IMPORTANT CONCEPTS TO HELP YOU UNDERSTANDYOUR HEALTH PLAN

The Chronic Illness Benefit covers a comprehensive list of chronic conditions that includes asthma, diabetes, high cholesterol and high blood pressure. The Chronic Disease List (CDL) is a defined list of chronic conditions we cover according to the Prescribed Minimum Benefits. You have full cover for approved medicine on the Schemes medicine list or up to a set monthly Chronic Drug Amount for medicine not on the medicine list. The Chronic Drug Amount is a monthly maximum amount we pay for a class of medicine. If you are registered on the Chronic Illness Benefit for diabetes and a defined list of heart-related conditions you can access our Personal Health Programmes to help better manage your condition.

CHRONIC ILLNESS BENEFIT

Day-to-day cover includes your visits to healthcare professionals out of hospital, radiology, pathology and medicines purchased for everyday use. We cover your day-to-day healthcare services from the Medical Savings Account and Insured Network Benefit. The level of day-to-day cover depends on the plan you choose.

DAY-TO-DAY COVER

This is a rate set by the Discovery Health Medical Scheme at which claims and services for healthcare providers (hospitals, pharmacies and healthcare professionals) will be paid.

DISCOVERY HEALTH RATE

This is the cover you get when you are admitted to hospital for emergency and planned hospital admissions. You have to get authorisation from us for your hospital stay. Your hospital cover is made up of your hospital account and related accounts. A related account is an account from your treating doctor, anaesthetist and any other approved healthcare services like pathology or radiology scans.

HOSPITAL COVER

This unique benefit gives you access to unlimited day-to-day cover for a set of healthcare services at a network provider when you have spent the annual funds in your Medical Savings Account. These healthcare services include GP consultation fees and maternity costs. The level of cover depends on the plan you choose.

INSURED NETWORK BENEFIT

CIB

INB

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Most in- and out-of-hospital healthcare benefits are unlimited, but there are some healthcare services that are subject to annual limits. It is important for you to familiarise yourself with these limits and to track your usage by logging onto www.discovery.co.za or checking your statements.

LIMITS

This is an amount that gets set aside for you at the beginning of the year or when you join the Scheme. You can use it for day-to-day healthcare expenses like doctors visits, optometry, medicine, pathology and radiology as long as you have money available. Money not used at the end of the year will be carried over to the next year.

MEDICAL SAVINGS ACCOUNT

This is a list of approved chronic medicines that the Scheme covers in full. The list includes an extensive range of high-quality medicines for all covered chronic conditions to ensure you always have the option of full cover.

MEDICINE LIST

The Delta options and Coastal Plan require you to use the Schemes network providers. If you use these providers we are able to keep your contributions as affordable as possible while ensuring full cover.

NETWORKS

The Scheme has entered into payment arrangements with various healthcare professionals that have agreed to be reimbursed at the Discovery Health Rate. This ensures that there are no co-payments for you. You benefit from access to the broadest range of GPs and specialists, which represents over 90% of members interactions with these healthcare professionals.

PAYMENT ARRANGEMENTS

PRESCRIBED MINIMUM BENEFIT CONDITIONS

These are conditions which all medical schemes are required to cover as set by the Medical Schemes Act and its regulations. You may be required to use a Designated Service Provider (DSP). A DSP is a hospital or a healthcare provider who has an agreement with Discovery Health Medical Scheme to provide treatment or services at a contracted rate and without any co-payments by you.

MSA

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INJURY ON DUTY HEALTHCARE CLAIMS

Discovery Health Medical Scheme pays for your healthcare expenses when youre involved in a motor vehicle accident according to your selected health plan and the rules of the Scheme. According to the rules of Discovery Health Medical Scheme, you need to lodge a claim with the Road Accident Fund. If your claim with the Road Accident Fund is successful and both Discovery Health Medical Scheme and the Road Accident Fund pay your medical expenses, youll need to pay back the medical expenses paid by the Road Accident Fund to Discovery Health Medical Scheme.

Discovery Health Medical Scheme pays for your healthcare expenses related to an injury at your workplace in accordance with the rules of the Scheme and your plan type. According to the Compensation for Occupational Injuries and Diseases Act, 1993, the Compensation Commissioner must pay for any treatment related to an injury on duty. All accidents or alleged accidents at work that entail medical expenses or absence from work for more that three days, or both, must be reported within seven days to the Compensation Commissioner. Discovery Health will help you with any questions and free administration of your injury on duty claim.

If your claim with the Compensation Commissioner is successful, and both Discovery Health Medical Scheme and Compensation Commissioner pay your accidental-related medical expenses, youll need to pay back the medical expenses paid by the Compensation Commissioner to Discovery Health Medical Scheme.

For any assistance with injury on duty claims, please contact Discovery Health Third Party Recovery Services on 011 529 5096/1419/3929.

MOTOR VEHICLE ACCIDENT CLAIMS DISCOVERY MEDICAL HEALTH SCHEME COVER FOR PMBs

In most cases, Discovery Health Medical Scheme plans offer benefits that are far richer than the Prescribed Minimum Benefits. To access Prescribed Minimum Benefits, there are rules that apply:

Your medical condition must qualify for cover and be part of the list of defined Prescribed Minimum Benefit conditions

The treatment needed must match the treatments in the published defined benefits

You must use Designated Service Providers (DSPs) in the Discovery Health network. This does not apply in life-threatening emergencies. However even in these cases, where appropriate and according to the rules of the Scheme, you may be transferred to a hospital and/or to a healthcare provider in the Discovery Health Network.

If your treatment doesnt meet the above criteria, we will pay up to 80% of the Discovery Health Rate. You will be responsible for the difference between what we pay and the actual cost of your treatment.

More information on our approach to Prescribed Minimum Benefits is available on www.discovery.co.za

IMPORTANT CONCEPTS TO HELP YOU UNDERSTANDYOUR HEALTH PLAN

Access your healthcare records and grant your doctor consent to view them

Order medicine for home delivery

Find a healthcare professional using MaPS, our online provider search functionality

Access important documents Track your benefits and medical spend

Submit and track your claims

View information on hospital procedures

Check medicine prices and alternatives

Plan and authorise hospital admissions

View your other Discovery products

Translate your travel cover into one of five languages

Watch educational videos

Consult with your doctor online See your Drs real time availability and instantly book an appointment

Activate HealthyCare

Download the Discovery appwww.discovery.co.za

YOUR DIGITAL WORLD OF DISCOVERYThe Discovery app and website have both been purpose-built to help you get the most out of your health plan

DISCOVERY GIVES YOU ACCESS TO A VARIETY OF VALUE ADDED BENEFITS THAT HELP YOU SAVE UP TO 25%

HealthyCareDiscovery has partnered with Clicks and Dis-Chem to help you save up to 25% on a vast range of products and services in the HealthyCare catalogue. Once you have activated HealthyCare, members will qualify for up to 10% cash back. Members on both the Discovery Health Medical Scheme and Vitality can boost their cash back up to 25% at one partner.

The Discovery HealthyCare catalogue provides you with unique savings on:

You can view the HealthyCare catalogue on www.discovery.co.za or in-store at Clicks and Dis-Chem.

Frames and lensesYou can get a 20% discount on your frames and eyeglass lenses when you visit an optometrist in the Discovery Health Optometry Network. The discount is immediate at point of sale and will help you preserve your Medical Savings Account.

Stem cell banking and semen preservation

Get up to 25% off on stem cell storage and semen preservation with Netcells Bioscience when you pay upfront. If you choose to use a payment plan, you get a discount of 20%.

Babycare items Dental care items Clinic nursing services

Eyecare items Footcare items Over-the-counter medicine (schedule 1 and schedule 2)

Wearable health and fitness devices

Emergency care itemsA selection of monitoring devices and specialised foods to manage your chronic condition

Suncare items Selfcare items

UNIQUE SAVINGS FROM DISCOVERY

Available at:

HealthyCare is brought to you by Discovery Vitality (Pty) Ltd. Registration number 1999/007736/07, an authorised financial services provider. Frames and Lenses and Netcells Bioscience is brought to you by Discovery Health (Pty) Ltd. Registration number 1997/013480/07, an authorised financial services provider.

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NOTES

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Discovery Health Medical Scheme is regulated by the Council for Medical Schemes. Contact details of the Council of Medical Schemes: 012 431 0500 | www.medicalschemes.com

The benefits explained in this brochure are provided by the Discovery Health Medical Scheme, registration number 1125, administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial

services provider. This brochure is only a summary of the key benefits and features of the Discovery Health Medical Scheme plans, awaiting formal approval from the Council for Medical Schemes. When reference is made to we in the context of benefits, members, payments or cover, in this brochure this is reference to the Discovery Health Medical Scheme. Vitality is not part of the Discovery Health Medical Scheme. Vitality is a separate product sold and administered by Discovery Vitality (Pty) Ltd. Registration number 1999/007736/07, an authorised financial services provider.

Discovery Health Medical Scheme | 16 Fredman Drive | Sandton | 0860 99 88 77 | www.discovery.co.za

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Saver Health Plan Guide 2015

Documents

Transcript of Saver Health Plan Guide 2015