Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
All treatments and procedures are subject to authorisation and protocols
All benefits are listed as an indication only. Please verify with your broker and scheme
Assume scheme pays all these costs, unless otherwise stated
non-Network Specialists:
Covered in full
Scheme rate is set by Discovery
network Specialists:
Covered in full
non-Network GPs:
Covered in full
network GPs:
Covered in full
Hospital Choice:
Full Cover Hospital Network: Covered in full
Otherwise, no cover unless emergency
Day procedures: KeyCare Start Day Surgery Network
Day Hospitals:
Certain procedures are covered in full at Day Hospital
Penalty for using other hospital:
See above
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
Admission that meet criteria for home-based care: R5,000 co-payment
* There might be other co-payments if you don't use scheme-chosen provider for some services.
* Treatment required for PMB level care is always paid by scheme, with no co-payment, if you follow the protocols. That means that these co-payments might not apply in your case! More info here
Specialised Radiology:
MRI and CT scans, Part of approved admission: Covered by scheme
MRI and CT scans, Not part of approved admission: R2,650 co-payment, from specialist benefit
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
Covered in full
No limits or co-payments for PMB level care and/or for emergency
Transplants:
Covered
Dialysis:
Covered in State facilities
Exclusions:
Dentistry
Tonsillectomies, Myringotomies and Adenoidectomies
Nail disorders
Skin disorders
Investigations
Functional nasal surgery
Elective caesarean section
Reflux surgery
Hiatus hernia
Back and neck treatment or surgery
Knee or shoulder surgery
Arthroscopy
Joint replacements
Endoscopic procedures (except for under 12yrs, or if related to surgery)
Cochlear implants
Bunions
Varicose veins
Refractive eye surgery
Non cancerous breast conditions
* Treatment required for PMB level of care is always paid by scheme, if you follow the protocols. It cannot be excluded. More info here.
* All schemes have extensive exclusions. We've tried to list the major ones here, but please consult your scheme or broker to get the full list
Alternatives to hospitals:
Palliative care at home: Unlimited, as approved
Physical and virtual 24-hour care for services such as postnatal care, end-of-life care, IV infusions (drips), COVID-19 and wound care.
Home monitoring device: up to R4,500 per person
Casualty:
li>After hours care at your chosen GP or network provider
All medical aids must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
This can include consults with specialists, blood or other tests, radiology and medicine
The benefit is paid by the scheme, and not out of your savings account
If you have no day-to-day funds, you still have cover for PMBs
Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
Access to the WELLTH Fund. You get up to R10,000 per family for various out of hospital expenses including GP, eye, dental, hearing screenings and medical devices. Find out more .
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
Medicines that are on medicine list and are prescribed by Network GP are paid for by scheme
Over-the-counter:
No benefit
Birth Control:
No benefit
On Discharge:
No benefit
Biological:
PMBs only
Treatment that is required (by law) for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here.)
Note:
Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
