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2014 YOUR GUIDE TO THE KEYCARE SERIES

Plus | Access | Core


KeyCare
Series
2014
The benefts explained in this brochure are provided by Discovery Health Medical Scheme, registraton number 1125, administered by Discovery Health (Pty) Ltd, registraton number 1997/013480/07,
an authorised fnancial services provider. This brochure is only a summary of the key benefts and features of Discovery Health Medical Scheme plans, awaitng formal approval from the Council for Medical
Schemes. When reference is made our or we in the context of benefts, members, payments or cover, in this brochure these are references to Discovery Health Medical Scheme. For compliance questons, email
compliance@discovery.co.za. Vitality is not part of Discovery Health Medical Scheme. Vitality is a separate product sold and administered by Discovery Vitality (Pty) Ltd. Registraton number 1999/007736/07, an authorised
fnancial services provider. MedSaver and ChroniCare are brought to you by Discovery Vitality.
YOUR HEALTHCARE COVER IN 2014
Our aim is to keep you healthy and provide you with the best of care when you need it most.
We design our integrated product solutons to make sure you get the most value from your
health plan, and to assist you in avoiding out-of-pocket payments wherever possible, especially
when you or your loved ones experience a critcal illness or major hospital admission. This
integrated approach to your healthcare is made possible by the combined power of Discovery
Health Medical Scheme and Discovery Health as well as Discovery Vitality.
Discovery Health Medical Scheme ofers the widest range of health plans in the market. It is
South Africas largest open medical scheme with over 2,5 million members and more than
50% share of the local open medical schemes market.
Discovery Health is the administrator of Discovery Health Medical Scheme, responsible for
many functons, including claims processing and payment, and client service touch points
such as the website and call centre.
Vitality is a separate Discovery company that ofers a wellness programme that you may
choose to join as a Discovery Health Medical Scheme member. Vitalitys ability to make
people healthier and give them great rewards has made it the worlds leading wellness
programme, with over fve million members on four contnents.
This guide gives you a summary of the KeyCare Series benefts. You will also fnd informaton
about the additonal benefts and tools provided by Discovery Health. Please familiarise
yourself with the informaton we have provided, so you can make the best choices when it
comes to your healthcare.
Regards
Milton Streak
Principal Ofcer:
Discovery Health Medical Scheme
Dr Jonathan Broomberg
CEO:
Discovery Health
Stay in touch with us
Discovery Vitality (Pty) Ltd is an authorised fnancial services provider. Registraton number: 1999/007736/07.
www.discovery.co.za facebook.com/discoveryhealthsa twiter.com/discovery_sa
Dear Member
Thank you for giving us the opportunity to look afer your healthcare cover needs
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KEYCARE SERIES
PRODUCT PLATFORM
Discovery Health Medical Scheme ofers a range of optons to cater for every need. The KeyCare Series ofers afordable cover at KeyCares networks
of hospitals and doctors.
Hospital cover
KeyCare Plans ofer cover in a defned network of hospitals.
On KeyCare Core and KeyCare Plus, we cover you in any private hospital for emergencies and planned hospital admissions that you have
authorised with us in the KeyCare network of hospitals.
On KeyCare Access, we cover emergencies and trauma in the Keycare Access Hospital and KeyCare Hospital networks of private hospitals.
We cover childbirth and care for your baby up to 12 months in the KeyCare Access Hospital Network, and all other hospital care is
covered in our contracted network of state facilites.
Chronic illness cover
You have cover for a list of 27 conditons on our Chronic Disease List, as long as your chronic medicine is on the
KeyCare medicine list. You need to get your approved medicine from one of our approved pharmacies or your chosen KeyCare
GP (if they dispense medicine).
Screening and preventon
The Screening and Preventon Beneft covers blood glucose, blood pressure, cholesterol and body mass index
measurements at a Discovery Wellness Network provider. The beneft 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
conditons, we also cover a seasonal fu vaccine.
Screening and preventon
KeyFIT
Day-to-day medical care
Chronic Illness Beneft
Planned
hospital care
Critcal
hospital care
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Discovery Vitality ofers the
worlds leading science-based
programme with a personalised
approach to wellness
Vitality helps you get healthier by
giving you the knowledge, tools and
motvaton to improve your health its
been clinically proven that engaged
Vitality members are healthier, live
longer and have lower healthcare costs.
Members on KeyCare Plus and KeyCare Access have cover for day-to-day healthcare such as GP visits, basic x-rays, blood,
urine, other fuid and tssue tests, medicine, dentstry and cover for eye care.
Day-to-day cover
Discovery Vitality (Pty) Ltd is an authorised fnancial services provider. Registraton number: 1999/007736/07.
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THE FULL COVER CHOICE
Our extensive networks of healthcare providers, combined with our unique self-service tools, mean you can avoid co-payments.
These tps will guide you to full cover. Remember to look out for the full cover stamp throughout this guide.
Use our extensive hospital networks
You are covered in full when you use a network hospital. Use our MaPS tool to fnd a hospital in our network.
1
Use a GP or specialist who we have a payment arrangement with
We ofer the broadest range of GP and specialist payment arrangements, which provides full cover both in hospital and out of hospital. Use our MaPS tool to fnd a
healthcare professional who we have a payment arrangement with.
2
You can access MaPS and MedXpress at www.discovery.co.za or on the Discovery app.
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Screening and preventon
KeyFIT
Day-to-day medical care
Chronic Illness Beneft
Planned
hospital care
Critcal
hospital care
Go for preventve screening tests
We cover preventve screening tests such as mammograms, blood pressure and cholesterol tests which are great at
detectng early warning signs of serious illness. Having these tests done helps you to stay healthy, because preventon
is beter than cure.
4
Use our preferred medicine
All Discovery Health Medical Scheme plans ofer a comprehensive list of medicine which we cover in full. Use Discovery MedXpress or ask
your pharmacist about your optons to avoid a co-payment. If you choose medicine not on our medicine list, you will have to pay for it.
3
Discovery Vitality (Pty) Ltd is an authorised fnancial services provider. Registraton number: 1999/007736/07.
8
IMPORTANT CONCEPTS TO HELP YOU
UNDERSTAND YOUR HEALTH PLAN
Use these handy defnitons to help you understand important concepts discussed in this guide.
Discovery Health Rate
This is a rate set by Discovery Health Medical Scheme at which claims and
services for healthcare providers (hospitals, pharmacies and healthcare
professionals) will be paid.
DHR
Chronic Illness Beneft (CIB)
You have cover for a list of 27 conditons on our Chronic Disease List, as long
as your chronic medicine is on the KeyCare medicine list. The Chronic Disease
List (CDL) is a defned list of chronic conditons we cover according to the
Prescribed Minimum Benefts. You need to get your approved chronic medicine
from one of our network pharmacies or from your chosen KeyCare GP (if he
or she dispenses medicine). You have full cover for approved medicine on the
Schemes medicine list (formulary). If you choose chronic medicine that is not
on our medicine list, you will have to pay for it.
Hospital cover
We cover you in hospital for emergency and planned hospital admissions.
You have to get authorisaton 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 treatng doctor, anaesthetst and any other approved
healthcare services like pathology or radiology.
Day-to-day cover
Day-to-day cover includes your visits to doctors out of hospital, blood tests and
medicines purchased for everyday use. Members on KeyCare Plus and KeyCare
Access have cover for day-to-day medical care.
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Networks
Some plans, benefts and healthcare services require you to use the Schemes
network providers. If you use these providers we are able to keep your
contributons as afordable as possible while ensuring full cover.
Medicine list (formulary)
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 conditons to ensure you always have an opton of full cover.
Payment arrangements
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 you have no co-payments.
Limits
Most in- and out-of-hospital healthcare benefts 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.
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IMPORTANT CONCEPTS TO HELP YOU
UNDERSTAND YOUR HEALTH PLAN
Claiming for healthcare afer a motor vehicle accident
Discovery Health Medical Scheme pays for your healthcare expenses when youre
involved in a motor vehicle accident according to your selected health plan and
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.
Claiming for healthcare afer an injury on duty
Discovery Health Medical Scheme pays for your healthcare expenses related to an
injury on duty at your workplace in accordance with the rules of the Scheme and your
plan type. According to the Compensaton for Occupatonal Injuries and Diseases Act,
1993, the Compensaton 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 than three days, or both, must be reported within
seven days to the Compensaton Commissioner. Discovery Health will help you with
any questons and free administraton of your injury on duty claim.
If your claim with the Compensaton Commissioner is successful and both
Discovery Health Medical Scheme and the Compensaton Commissioner pay your
accident-related medical expenses youll need to pay your medical expenses paid
by the Compensaton 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.
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What Prescribed Minimum Beneft (PMB) conditons are
These are conditons which all medical schemes are required to cover as set by the Council for Medical Schemes according to clinical guidelines. You may be required to use a Designated
Service Provider (DSP). A DSP is a hospital or 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.
Cover for Prescribed Minimum Benefts
In most cases, Discovery Health Medical Scheme plans ofer benefts that are far richer than the Prescribed Minimum Benefts. To access Prescribed Minimum Benefts, there are rules that apply:
Your medical conditon must qualify for cover and be part of the list of defned Prescribed Minimum Beneft conditons
The treatment needed must match the treatments in the defned benefts
You must use Designated Service Providers 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 healthcare provider in the Discovery Health network otherwise we will pay up to 80% of the Discovery Health Rate.
You will be responsible for the diference between what we pay and the actual cost of your treatment.
More informaton on our approach to Prescribed Minimum Benefts is available on www.discovery.co.za
PRESCRIBED MINIMUM BENEFITS
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Plus | Access | Core
KeyCare Series Plan range
KEY FEATURES
Screening and preventon
KeyFIT
Day-to-day medical care
Chronic Illness Beneft
Planned
hospital care
Critcal
hospital care
Unlimited hospital cover in our KeyCare network of hospitals
Guaranteed full cover in hospital for specialists on the KeyCare network, and up to 100% of the
Discovery Health Rate for other healthcare professionals
Essental cover for chronic medicine on the KeyCare medicine list for all
CDL chronic conditons
Unlimited cover for medically appropriate GP consultatons, blood tests, x-rays or medicine in our
KeyCare network on the KeyCare Plus and KeyCare Access Plans
Discovery Vitality (Pty) Ltd is an authorised fnancial services provider. Registraton number: 1999/007736/07.
13
PLAN SPECIFIC INFORMATION
KeyCare Series Plan range
The KeyCare Series has three health plan types. These are:
KeyCare Plus
KeyCare Access
KeyCare Core
There are slight diferences in benefts as highlighted on the
next page. The benefts not mentoned in the table are the
same across both plans.
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PLAN SPECIFIC INFORMATION
KeyCare Plus KeyCare Access KeyCare Core
Hospitals Unlimited cover in the KeyCare Hospital
Network. There is a list of procedures
that are covered in the KeyCare day
surgery network.
Unlimited cover for emergencies, trauma,
childbirth and care for your newborn in the
KeyCare Access network of private hospitals.
Other conditons are covered in a contracted
network of state facilites.
Unlimited cover in the KeyCare Hospital
Network. There is a list of procedures
that are covered in the KeyCare day
surgery network.
Day-to-day medical cover
Primary care cover through your chosen GP and day-to-day medicine from our medicine list.
This plan does not ofer day-to-day
medical cover.
Private specialist cover up to a limit of R2 750
for each person.
Private specialist cover up to a limit for
emergencies, trauma, childbirth and cover for
your baby up to 12 months afer childbirth.
Private specialist cover up to a limit of R2 750
for each person.
KeyCare plans ofer you the best and most afordable cover through the KeyCare network of hospitals and doctors. The KeyCare Series has three health plan types; there
are slight diferences in the beneft structure as highlighted below. The benefts not mentoned in the below table and on the next page are the same across all plans.
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PLAN SPECIFIC INFORMATION
KeyCare Plus KeyCare Access KeyCare Core
Casualty visits Cover in any casualty unit at one of the KeyCare
network hospitals.
You have to pay the frst R225 of the
consultaton.
Other than for emergencies and trauma, you
have cover in any casualty unit at one of the
KeyCare Access Hospitals and KeyCare network
hospitals once a year. You have to pay the frst
R225 of the consultaton.
Casualty visits are not covered.
Chronic medicines prescriptons Your chosen KeyCare GP must prescribe your approved chronic medicine. Any GP can prescribe your approved medicine.
Cancer We cover treatment if it is a Prescribed
Minimum Beneft and if you go to a cancer
specialist in our network.
We cover treatment if it is a Prescribed
Minimum Beneft in a state facility.
We cover treatment if it is a Prescribed
Minimum Beneft and if you go to a cancer
specialist in our network.
Trauma Recovery Extender Beneft Out-of-hospital claims for recovery afer certain traumatc events are covered on this beneft for
the rest of the year in which the trauma took place, and a year afer the trauma.
This plan does not ofer this beneft.
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Always keep your membership card with you; it identfes you as a KeyCare member. Your membership card helps you get access to your benefts.
Always use your chosen GP or a hospital in the KeyCare network.
Check with your GP that your treatment or medicine is on our list of covered services.
If your GP decides you have to see a specialist, your GP will get approval from us so that you can go to the specialist. Make sure you take the reference number with you when
you visit the specialist.
In an emergency, go straight to hospital. If you are going to hospital for a planned procedure, call us to confrm your benefts before you are admited. This way, you will always
know what you are covered for.
WHAT TO DO TO GET THE MOST
OUT OF YOUR KEYCARE PLAN
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Cover
in hospital
the best of care
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Medical emergency
A medical emergency is the sudden and, at the tme, unexpected onset of a health conditon
that needs immediate medical or surgical treatment, where failure to provide medical
or surgical treatment would result in serious impairment to bodily functons or serious
dysfuncton of a bodily organ or part, or would place the persons life in serious jeopardy in
line with the Schemes rules and Medical Schemes Act.
What to do in a medical emergency
In an emergency, go straight to hospital. If you need medically equipped transport, call
0860 999 911. This line is managed by highly qualifed emergency personnel who will
send air or road emergency evacuaton transport to you, depending on which is most
appropriate.
Your hospital cover is made up of:
Cover for the account of your hospital stay
Cover for the accounts from your admitng doctor, anaesthetst or any other approved
healthcare professional.
Cover for your hospital account on KeyCare Core and KeyCare Plus
We cover you in any hospital in the KeyCare network of hospitals. If you dont go to a
KeyCare network hospital for planned admissions, you will have to pay the claims yourself.
We cover these procedures in our day surgery network:
Adenoidectomy
Arthrocentesis (joint
injecton)
Cataract surgery
Cautery of vulva warts
Circumcision
Colonoscopy
Cystourethroscopy
Diagnostc D&C
Gastroscopy
Hysteroscopy
Myringotomy
Myringotomy with
intubaton (grommets)
Prostate biopsy
Proctoscopy
Removal of pins and plates
Sigmoidoscopy
Simple abdominal hernia
repair
Simple nasal procedure for
nose bleeding (that is, nasal
plugging and nasal cautery)
Tonsillectomy
Treatment of Bartholins
cyst/abscess
Vasectomy
Vulva/cone biopsy
HOSPITAL COVER
There is no overall hospital limit. If you have to stay in hospital for a long tme, or if your treatment is very expensive, your cover wont run out. Some healthcare
services and procedures have a limit or we may have rules on how we pay for them.
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Cover for your hospital account on KeyCare Access
On KeyCare Access, healthcare services for approved admissions for emergencies, trauma,
childbirth and care for your baby up to 12 months afer childbirth are covered in our
network of private hospitals with no overall limit. We pay approved admissions for all other
hospital care in our network of state facilites.
We cover the following traumas in our network of private hospitals
Injuries at work
Burns
Injuries from a crime
Sexual assault
Injuries from a car accident
Injuries from a fall
The loss of an arm, hand,
leg or foot
Near drowning
Head injuries
Poisoning or a serious
allergic reacton that may
cause death
Care for your baby afer childbirth on KeyCare Access
This beneft covers babies that are registered on the Scheme from their date of birth when
born to a parent registered on the Scheme. It covers approved hospital admissions in our
network of private hospitals for the baby for 12 months from the babys date of birth.
Babies not added to the Scheme from their date of birth will be covered in our contracted
network of state facilites.
Cover for related accounts
We guarantee full cover when you use specialists and healthcare professionals on the
KeyCare network.
Other specialists and healthcare professionals
If you are treated by a specialist who we dont have an arrangement with and other
healthcare professionals, we pay up to 100% of the Discovery Health Rate. If the healthcare
professional charges more than the Discovery Health Rate, you must pay the rest.
HOSPITAL COVER
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Cover for going to casualty
If you are admited to hospital from casualty, we will cover the costs of the casualty visit
from your Hospital Beneft, as long as we confrm your hospital admission.
On KeyCare Plus, you can go to any casualty unit at one of the KeyCare network hospitals.
You have to pay the frst R225 of the casualty account if you are not admited to hospital
from casualty.
For emergencies and trauma on KeyCare Access, you can go to any casualty unit at one
of the KeyCare Access or KeyCare network hospitals. For visits, other than emergencies
and trauma on KeyCare Access, each person can go to casualty at one of the KeyCare
network hospitals once a year. You have to pay the frst R225 of the casualty account if
you are not admited.
Your cover for MRI and CT scans
MRI and CT scans are like x-rays, but show much more detail. They are used when an x-ray
doesnt show enough. If your scan is related to an approved hospital stay in our network of
private hospitals, we pay for it from your Hospital Beneft. If it is not, we pay for it from your
Specialist Beneft, up to R2 750 for each person. We do not pay for MRI or CT scans that are
related to conservatve back or neck treatment (this is treatment for your back or neck that
is not surgery).
Unlimited healthcare services
Most of your in-hospital healthcare services have no overall limit.
These are:
GPs
Specialists
Allied healthcare professionals, like physiotherapists
Pathology and radiology
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HOSPITAL COVER
Some healthcare services have an annual limit
KeyCare Core and KeyCare Plus KeyCare Access
Mental health 21 days for each person
21 days for each person covered in our contracted network of
state facilites.
Alcohol and drug rehabilitaton 21 days for each person
21 days for each person covered in our contracted network of
state facilites.
Cataract surgery
We cover cataract surgery as long as we have approved
your treatment at a doctor and facility in our network for
cataract surgery.
Covered in our contracted network of state facilites.
Chronic dialysis
We cover these expenses in full as long as we have approved
your treatment at a doctor and facility in our network.
We cover these expenses in full as long as we have approved your
treatment at a doctor and facility in the KeyCare Access Network.
Compassionate care R28 500 for each person in their lifetme
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HOSPITAL NETWORKS
KEYCARE HOSPITAL NETWORKS
You must go to one of these hospitals for planned hospital admissions. If you do not use one of these hospitals for a planned admission, you will need to pay your claims.
KeyCare Core and KeyCare Plus Hospital Network
KeyCare Access trauma and emergency network
Eastern Cape
East London
Life Beacon Bay Hospital
Life East London Private Hospital
Life St James Operatng Theatres
Life St Dominics Private Hospital
Humansdorp
Life Isivivana Private Hospital
Port Elizabeth
Life New Mercantle Hospital
Queenstown
Life Queenstown Private Hospital
Uitenhage
Netcare Cuyler Clinic
Umtata
Life St Marys Private Hospital
Free State
Bethlehem
Hoogland Medi-Clinic
Bloemfontein
Bloemfontein Eye Centre
Netcare Pelonomi Private Hospital
Life Rosepark Clinic
Life Pasteur Hospital
Netcare Universitas Private Hospital
Welkom
Ernest Oppenheimer Hospital
Welkom Medi-Clinic
St Helena Hospital
Gauteng
Benoni
Life The Glynwood Hospital
Boksburg
Botshelong Empilweni Clinic
(Clinix Vosloorus)
Sunshine Hospital
Brakpan
Life Dalview Clinic
Germiston
Life Roseacres Clinic
Heidelberg
Life Suikerbosrand Clinic
Johannesburg
Netcare Rand Clinic
Johannesburg Eye Clinic
Netcare Garden City Clinic
Life Brenthurst Clinic
Kempton Park
Arwyp Medical Centre
Lakefeld
Netcare Optklin Eye Hospital
Lenasia
Lenmed Clinic
Midrand
Life Carstenhof Clinic
Pretoria
Netcare Bougainville Private Hospital
Centurion Eye Hospital
Life Eugene Marais Hospital
Netcare Jakaranda Hospital
Legae Medi-Clinic
Louis Pasteur Hospital
Medforum Medi-Clinic
Muelmed Hospital
Pretoria Eye Insttute
Zuid-Afrikaans Hospital
Randfontein
Life Robinson Hospital
Lenmed Randfontein Private Hospital
Sasolburg
Netcare Vaalpark Hospital
Soweto
Clinix Private Hospital Tshepo Themba
Clinix Private Hospital Lesedi
Springs
Life Springs Parkland Clinic
Life St Marys Womens Clinic
Thembisa
Zamokuhle Private Hospital
Vanderbijlpark
Emfuleni Medi-Clinic
Ocumed
Vereeniging
Clinix Private Hospital Sebokeng
Midvaal Private Hospital
Westgate
Medgate Day Clinic
KwaZulu-Natal
Amanzimtot
Netcare Kingsway Hospital
Chatsworth
Life Chatsmed Garden Hospital
Durban
Life City Hospital
Life Entabeni Hospital
Empangeni
Life Empangeni Garden Clinic
Isipingo
Life Isipingo Clinic
On KeyCare Access we pay approved admissions for hospital care other than emergencies, trauma, childbirth and care for your baby in a contracted state facilites.
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HOSPITAL NETWORKS
KEYCARE HOSPITAL NETWORKS
Kokstad
Kokstad Private Hospital
Ladysmith
La Verna Hospital
Newcastle
Newcastle Private Hospital
Phoenix
Life Mount Edgecombe
Pietermaritzburg
Midlands Medical Centre
Netcare St Annes Hospital
Pinetown
Life Crompton Hospital
Port Shepstone
Hibiscus Hospital
Richards Bay
Netcare The Bay Hospital
Sydenham
Nu Shifa Hospital
Tongaat
Victoria Private Hospital (Tongaat)
Limpopo
Bela-Bela
St Vincents Hospital
Phalaborwa
Clinix Phalaborwa Private Hospital
Polokwane
Limpopo Medi-Clinic
Thabazimbi
Thabazimbi Medi-Clinic
Tzaneen
Tzaneen Medi-Clinic
Mpumalanga
Barberton
Barberton Medi-Clinic
Emalahleni
Life Cosmos Hospital
Emalahleni Day Hospital
Ermelo
Ermelo Private Hospital
Middelburg
Life Middelburg Private Hospital
Nelspruit
Nelspruit Private Hospital
Trichardt
Highveld Medi-Clinic
North West
Carletonville
Leslie Williams Private Hospital
Western Deep Clinic
Klerksdorp
Life Anncron Clinic
Mafkeng
Victoria Private Hospital (Mafkeng Hospital)
Orkney
West Vaal Clinic
Potchefstroom
Potchefstroom Medi-Clinic
Rustenburg
Life Peglerae Hospital
Northern Cape
Kathu
Kathu Medi-Clinic
Kimberley
Kimberley Medi-Clinic
Upington
Upington Private Hospital
Vryburg
Vryburg Private Hospital
Western Cape
Bellville
Bellville Medical Centre
Louis Leipoldt Medi-Clinic
Cape Town
Netcare Christaan Barnard Memorial Hospital
Netcare UCT Medical Centre
Ceres
Ceres Private Hospital
Gatesville
Gatesville Medical Centre
George
Geneva Clinic
George Medi-Clinic
Hermanus
Hermanus Medi-Clinic
Kuils River
Netcare Kuils River Private Hospital
Milnerton
Milnerton Medi-Clinic
Mitchells Plain
Mitchells Plain Medical Centre
Mossel Bay
Bayview Hospital
Oudtshoorn
Cango Day Clinic
Klein Karoo Medi-Clinic
Paarl
Paarl Medi-Clinic
West Coast
Life West Coast Private Hospital
Worcester
Worcester Medi-Clinic
Lesotho
Willies Hospital
On KeyCare Access we pay approved admissions for hospital care other than emergencies, trauma, childbirth and care for your baby in a contracted state facilites.
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HOSPITAL NETWORKS
KEYCARE HOSPITAL NETWORKS
Eastern Cape
Kokstad
Netcare Kokstad Hospital
Port Elizabeth
Life New Mercantle Hospital
Uitenhage
Netcare Uitenhage Hospital
Umtata
Life St Marys Private Hospital
Free State
Bloemfontein
Netcare Pelonomi Private Hospital
Gauteng
Alberton
Netcare Clinton Hospital
Johannesburg
Netcare Rand Clinic
Krugersdorp
Netcare Krugersdorp Hospital
Pretoria
Netcare Femina Hospital
Legae Medi-Clinic
Louis Pasteur Hospital
Sasolburg
Netcare Vaalpark Hospital
Soweto
Clinix Private Hospital Lesedi
Springs
Netcare N17 Hospital
Tembisa
Zamokhule Private Hospital
Kwazulu-Natal
Amanzimtot
Netcare Kingsway Hospital
Ladysmith
La Verna Hospital
Pietermaritzburg
Netcare St Annes Hospital
Richards Bay
Netcare The Bay Hospital
Tongaat
Victoria Private Hospital (Tongaat)
Limpopo
Phalaborwa
Clinix Phalaborwa Private Hospital
Polokwane
Limpopo Medi-Clinic
Tzaneen
Tzaneen Medi-Clinic
Mpumulanga
Nelspruit
Nelspruit Medi-Clinic
North West
Rustenburg
Netcare Ferncrest Hospital
Western Cape
Gatesville
Gatesville Medical Centre
Kuils River
Netcare Kuils River Private Hospital
Milnerton
Milnerton Medi-Clinic
Mitchells Plain
Mitchells Plain Medical Centre
Paarl
Paarl Medi-Clinic
Northern Cape
Kimberley
Kimberley Medi-Clinic
KeyCare Access Hospital Network for childbirth and care for your baby
On KeyCare Access we pay approved admissions for hospital care other than emergencies, trauma, childbirth and care for your baby in a contracted state facilites.
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Cover for
chronic illness,
cancer and HIV
the best of care
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CHRONIC ILLNESS, CANCER AND HIV COVER
Your cover for chronic conditons
You have cover for a list of chronic conditons, as long as your chronic medicine is on the
KeyCare medicine list. We need to approve your applicaton before we cover your conditon
from the Chronic Illness Beneft.
On the KeyCare Plus and KeyCare Access Plans, your chosen KeyCare GP must prescribe
your approved chronic medicine. On the KeyCare Core Plan, any GP can prescribe your
approved medicine.
How we pay for medicine
You need to get your approved chronic medicine that is on the KeyCare medicine list from
one of our network pharmacies or from your chosen KeyCare GP (if he or she dispenses
medicine). If you get your medicine from anywhere else, you will have to pay 20% of the
Discovery Health Rate for medicines. If you use chronic medicine that is not on our medicine
list, you will have to pay for it yourself.
Cover for cancer
We cover you for cancer treatment on the DiscoveryCare Oncology Programme. If youre
diagnosed with cancer you need to register for the programme.
On the KeyCare Core and KeyCare Plus Plans, we cover cancer treatment if it is a Prescribed
Minimum Beneft and if you go to a cancer specialist in our network.
On KeyCare Access, we cover cancer treatment if it is a Prescribed Minimum Beneft in a
state facility.
Cover for HIV and AIDS
When 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-efectve treatment and you can
be assured of confdentality at all tmes. We cover four GP consultatons, a specialist visit,
blood tests, scans and x-rays at a network provider. Approved medicines on our medicine
list are covered in full. You need to get your medicine from a Designated Service Provider to
avoid a 20% co-payment.
27
Cover for
day-to-day medical
expenses
the best of care
28
DAY-TO-DAY COVER
Cover for GP visits
When joining, you must choose a GP from the KeyCare GP network. You must go to your chosen GP for us to cover your
consultatons and some minor procedures.
Blood, urine and other fuid and
tssue tests
We pay for a list of blood, urine and other fuid and tssue tests. Your chosen GP must ask for these tests by flling in a KeyCare
pathology form.
Day-to-day medicine We pay for medicines from our medicine list if they are prescribed by your chosen KeyCare network GP.
You get one out-of-network GP
visit
If you need to see a doctor and your chosen GP from our network is not available for you to see, each person on your
membership can go to any other GP once a year. We will cover the GP visit, with selected blood tests and x-rays and medicines
on our medicine list.
Cover for dentstry We cover consultatons, fllings and tooth removals at a dentst in our dentst network.
Cover for eye care
We cover one eye test for each person, but you must go to an eye doctor in our network. The eye doctor will have a specifc
range of glasses that you can choose from. You can get a set of contact lenses instead of glasses if you choose to. You can get
new glasses or contact lenses every 24 months.
Applicable to KeyCare Plus and KeyCare Access Plans
29
Basic x-rays We pay for a list of basic x-rays at a network provider. Your chosen GP must ask for the x-rays to be done.
Casualty visits
On KeyCare Plus you can go to any casualty unit at one of the KeyCare network hospitals. You have to pay the frst R225 of the
consultaton.
On KeyCare Access, other than for emergencies and trauma, each person can go to casualty at one of the KeyCare network
hospitals once a year. You have to pay the frst R225 of the consultaton. You dont need to call us if you go to casualty.
Trauma Recovery Extender
Beneft
We will cover specifc out-of-hospital claims for your recovery afer certain traumatc events. Well cover you for the rest of the
year in which the trauma took place, and in the year afer your trauma. You may need to apply for this beneft. This doesnt
apply to KeyCare Core.
Medical equipment
We cover wheelchairs, wheelchair bateries and cushions, transfer boards and mobile ramps, commodes, long-leg calipers,
crutches and walkers on the medical equipment list, if you get them from a network provider. There is an overall limit of R4 450
for each family.
Other types of healthcare
professionals
We do not cover other types of healthcare professionals, such as physiotherapists, psychologists, speech therapists, audiologists,
homeopaths or chiropractors from your day-to-day benefts.
DAY-TO-DAY COVER
30
Specialist Beneft
Each person is covered up to R2 750. Your GP must get a reference number before your consultaton with the specialist. If you
need to see a dental specialist, eye specialist (opthalmologist) or a specialist for maternity care, you do not need a referral from
your GP or a reference number from us.
The KeyCare Access Plan covers specialist visits in our network for maternity, care for your baby up to 12 months, trauma and
emergencies up to the limit. You have to register your baby as soon as it is born. For all other healthcare services we cover
specialists employed by a state facility.
Preventve screening
The Screening and Preventon Beneft 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) and HIV screening tests. Members 65 years or older and members registered for certain chronic conditons are also
covered for a seasonal fu vaccine.
Antenatal Beneft
If you are pregnant, the Antenatal Beneft covers you at 100% of the Discovery Health Rate for the following healthcare services:
Four visits to a midwife or gynaecologist/obstetrician
One routne scan (between 10 and 20 weeks)
Selected blood tests requested by your gynaecologist/obstetrician
BENEFITS THAT ENHANCE YOUR COVER
31
GENERAL
EXCLUSIONS
Discovery Health Medical Scheme has certain exclusions. We do not pay for healthcare services related to the following, except where stpulated as part of a defned beneft or
under the Prescribed Minimum Benefts.
General exclusion list
Cosmetc procedures and treatments
Otoplasty for bat ears, port-wine stains and blepharoplasty (eyelid surgery)
Breast reductons or enlargements and gynaecomasta
Obesity
Frail care
Infertlity
Wilfully self-inficted illness or injury
Alcohol, drug or solvent abuse
Wilful and material violaton of the law
Wilful partcipaton in war, terrorist actvity, riot, civil commoton, rebellion or uprising
Injuries sustained or healthcare services arising during travel to or in a country at war
Experimental, unproven or unregistered treatments or practces
Search and rescue
Any costs for which a third party is legally responsible
We also do not cover the complicatons or the direct or indirect expenses that arise from
any of the exclusions listed above, except where stpulated as part of a defned beneft or
under the Prescribed Minimum Benefts.
Waitng periods
If we apply waitng periods because members have never belonged to a medical scheme
or have had a break in membership of more than 90 days before joining Discovery Health
Medical Scheme, they will not have access to the Prescribed Minimum Benefts during their
waitng periods. This includes cover for emergency admissions.
32
KEYCARE SERIES
EXCLUSIONS
In additon to the general exclusions that apply to all plans, the KeyCare Series does not cover the following, except if the Prescribed Minimum Benefts say schemes must:
1. Hospital admissions related to:
Dentstry
Nail disorders
Skin disorders
Investgatons and diagnostc work-up
Functonal nasal surgery
Electve caesarean secton, except if medically necessary
Surgery for oesophageal refux and hiatus hernia
Back and neck treatment or surgery
Joint replacements, including but not limited to hips, knees, shoulders
and elbows
Cochlear implants, auditory brain implants and internal nerve stmulators this
includes procedures, devices and processors
Healthcare services that should be done out of hospital and for which an
admission to hospital is not necessary
2. Correcton of Hallux Valgus/Bunion and Tailors Bunion/Bunionete
3. Arthroscopy
4. Removal of varicose veins
5. Refractve eye surgery
6. Non-cancerous breast conditons
7. Healthcare services outside South Africa
We also do not cover the cost of treatment for any complicatons or the direct or indirect
expenses related to any of these excluded conditons and treatments.
The benefts outlined in this guide are a summary of the plans registered in the medical scheme rules. These benefts 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 Protecton Act where it relates to the business of a medical scheme.
33
CONTRIBUTIONS
Total contributons
Main member Adult Child*
KeyCare Plus (8 801+) R1 448 R1 448 R388
KeyCare Plus (6 651-8 800) R973 R973 R272
KeyCare Plus (0-6 650) R695 R695 R251
KeyCare Access (8 801+) R1 416 R1 416 R381
KeyCare Access (6 651- 8 800) R942 R942 R267
KeyCare Access (4 151-6 650) R653 R653 R235
KeyCare Access (0-4 150) R490 R490 R212
KeyCare Core (8 801+) R1 070 R1 070 R241
KeyCare Core (6 651-8 800) R693 R693 R171
KeyCare Core (0-6 650) R556 R556 R143
* We count a maximum of three children when we work out the monthly contributons.
34
CLAIMING
Submitng proof of claims payment
Discovery Health Medical Scheme strives to pay your claims as quickly and as accurately
as possible. If you have paid a claim up front, you need to provide proof of payment to be
refunded. We will only accept the following as proof of payment:
A receipt
An internet bank transacton
A Paid stamp on your claim
Wording in your claim indicatng that you, the member or patent have paid
Credit column on the claim with an amount showing
This will ensure tmely and correct payment of your claim.
What to remember when claiming
Claims must be submited within four months from the end of the month in which the
service was rendered. Older claims will be considered expired and will not be paid.
Make sure that your membership number, the healthcare professionals details
including the practce number are clear on the claim.
Send a detailed claim and not just a receipt as we need the details of what you are
claiming for to process your claim quickly and correctly.
How to submit your claims
Smartphone App Submit and keep track of your claims using the Discovery app
on your iPhone or Android smartphone. Log into the app, select claims and then
submit claims and follow the instructons. Download the app from the App Store or
Google Play store.
Upload On your laptop, smartphone or tablet, go to www.discovery.co.za. On the
menu, hover over Health and click on Claims then select upload your claims. Upload
now and follow the steps.
Email Scan and email your claims to claims@discovery.co.za
Post Post your claims to Discovery Claims, PO Box 784262, Sandton 2146
Fax Fax your claims to 0860 329 252 (please ensure that the fax details are clear by
frst making a photocopy and then faxing that through).
35 35
Additonal
informaton
36
UNIQUE SAVINGS
ONLY WITH DISCOVERY HEALTH
If you are registered on the Chronic Illness Benefit you get up to 25% cash back on a range of
specialised products at Dis-Chem Pharmacies countrywide. You get cash back on a selection of
monitoring devices, speciality food, health education, footwear and accessories as well as fitness
and wellbeing items. Go to www.discovery.co.za/info/chronicare to register, view the catalogue
of products and for more information.
You get up to 25% cash back with MedSaver on over-the-counter (schedule 1 and 2) medicines at
Clicks Pharmacies. Go to www.discovery.co.za or www.medsaver.co.za to actvate MedSaver now and
start earning your cash back.
Discovery Health has partnered with Clicks, Dis-Chem and Netcells to help you save up to 25% on healthcare-related spend.
37
You get an exclusive discount of 25% when you pay upfront for umbilical cord blood and tssue stem
cell banking with Netcells Biosciences. When you choose to use a payment plan, you get a discount
of 20%. Go to www.discovery.co.za for more informaton.
38
MEDXPRESS
DOOR-TO-DOOR MEDICINE DELIVERY
H
o
m
e
W
o
rk
H
o
lid
a
y
Have your monthly
medicines delivered
to your door.
Delivering wherever you are
2014
Delivering the best of care
MedXpress, Discovery Healths convenient medicine delivery service
Now you can take standing in a long queue at the pharmacy of your already-overfowing to-do lists. MedXpress lets you order medicine online or over the phone and have it delivered
directly to your door. MedXpress is also the convenient way to order repeatable medicine prescriptons. You have full cover for medicines on the Discovery Health medicine list (formulary).
This means that you wont have to make any co-payments and you wont be charged above the Discovery Health Rate for medicines.
39
What Discovery MedXpress ofers 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 afect your
cover for chronic medicine when you call us to order your medicine.
Advice to help you save
When using MedXpress, Discovery Healths qualifed service agents can also advise you
on the most cost-efectve alternatves. And you will always be charged at the Discovery
Health Rate for medicines or less in efect getng rid of all those small co-payments that
add up over tme.
Important points to remember
Delivery
Chronic or repeatable prescripton medicine will be delivered to your preferred address
anywhere in South Africa.
Once-of prescripton medicine delivery orders are currently only available in
Johannesburg, Pretoria and Cape Town metropolitan areas.
How you can order medicine
If youre placing your order for the frst tme, you need to clearly mark your prescripton
with the words MedXpress and your Discovery Health Medical Scheme membership
number. You can email your prescripton to medxpress@discovery.co.za or fax it to
011 539 1020 and you will receive an SMS from Discovery Health MedXpress. Once youve
placed your frst order for chronic medicine you can use the Discovery smartphone app
(downloadable in the App Store or Google Play), you can log in to www.discovery.co.za or
call us to have your monthly repeat medicine orders delivered to an address of your choice.
There is no additonal administraton or delivery cost, so you can take back the tme spent
in the pharmacy by placing your order now.
40 40
THE DIGITAL WORLD OF DISCOVERY
www.discovery.co.za
and the Discovery app
Our website has been designed to
display optmally, whether you are
accessing it from a desktop, laptop,
tablet or smartphone.
The Discovery app available on the
App Store and Google Play puts your
health plan in your pocket.
Together they provide a wealth of self-
service tools and informaton to help
you manage your health plan and your
health. Anytme, Anywhere.
Translate your travel
cover into one of fve
languages
Watch our educatonal
videos
Access your health
records and grant your
doctor consent to view
them too
Check medicine price
and alternatves*
View other Discovery
products you have
View informaton on
hospital procedures
Find a healthcare
professional
Track your benefts and
medical spend
Plan and authorise
hospital admission*
Order medicine for
home delivery
Access important
documents
Submit and track
your claims
*Only available on www.discovery.co.za
41 41
HEALTHID PUTTING YOUR MEDICAL
INFORMATION IN YOUR DOCTORS HANDS
HealthID puts your health records in your doctors hands. This is the frst electronic health record applicaton of its kind in South Africa.
With Discovery Healths HealthID tablet app doctors can:
To beneft 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 informaton.
Apply for chronic cover
If you are diagnosed with a chronic conditon, your doctor
can complete an electronic Chronic Illness Beneft applicaton
using the HealthID app. This applicaton is easy and convenient,
because your doctor gets the informaton they need for your
specifc conditon when completng the applicaton and you
can get immediate approval for certain conditons.
Access medical histories and electronic health records
A doctor can go into your electronic health records and access
your health informaton to see your medical history. So, if you are
having trouble remembering partcular medicines youve taken, this
informaton is available to your doctor immediately. You can save tme
and money by not having to repeat tests and investgatons, because
the results of your previous tests are available for your doctor to see.
View beneft informaton
Your doctor also has instant access to your health
beneft informaton to help you get the most out of
your benefts. All these functons are designed to make
doctors visits easier and more productve.
Write electronic scripts
Your doctor can prescribe medicine during a consultaton with you using
electronic scriptng. Your doctor can also see medicines on the approved
medicine list, as well as the cost of those medicines. You can fnd ways
to reduce or even avoid co-payments on your medicines before you even
reach the pharmacy.
42
NOTES
GM_23378DHM_19/12/13_V10 KCFFE 10/13(14)
Discovery Health Medical Scheme|16 Fredman Drive|Sandton|0860 99 88 77|www.discovery.co.za
Discovery Health (Pty) Ltd registration 1997/013480/07, administers Discovery Health Medical Scheme, Registration number 1125.
Discovery Health (Pty) Ltd is an authorised financial services provider.

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