Cover for medicine
Discovery Health covers medicine either from the Chronic Illness Benefit or from your day-to-day benefits, where applicable.
Prescribed medicine
Prescribed medicine is non-chronic medicine. In other words, you generally do not take it for a long time and the condition it is taken for clears up.
This section explains how Discovery Health covers prescribed medicines in 2010 as well as the difference between generic and non-generic medicines as we pay these differently.
Find out how prescribed medicine is covered on your plan.
Executive Plan
Prescribed medicine is paid from the day-to-day benefits
Discovery Health pays for prescribed medicines from the money available in your day-to-day benefits. This could be your Medical Savings Account or Above Threshold Benefit.
We pay medicines up to the Discovery Health Medication Rate. Claims for prescribed medicines (schedule 3 and above) count towards the yearly prescribed medicine limit.
We classify medicines into categories
The medicine categories are:
- generic medicines
- non-generic medicines
- over-the-counter and life-style enhancing medicines
- excluded items, like contact lens solutions etc.
A summary of how we pay prescribed medicines on your plan
| Type of medicine | How we pay the claim from your Medical Savings Account | How we pay the claim from the Above Threshold Benefit | How we add the claim to the Annual Threshold and annual limits |
|---|---|---|---|
| Generic medicine(schedule 3 and above) | Up to 100% of the Discovery Health Medication Rate | ||
| * Non-generic medicines (schedule 3 and above) | Up to 100% of the Discovery Health Medication Rate | Up to a maximum of 90% on the Discovery Health Medication Rate | |
| Over-the-counter medicine (schedule 0, 1 and 2) and certain lifestyle enhancing medicine (schedule 2 and above) | Up to 100% of the Discovery Health Medication Rate | Not covered | Does not add up |
| Exclusions | Not covered | Not covered | Not covered |
*For non-generic medicine where the claimed amount is less than 75% of the Discovery Health Medication Rate, 75% of the claimed amount will add up to the Annual Threshold and yearly prescribed medicine limit.
Please note this structure does not apply to medicine approved for payment from the Chronic Illness Benefit.
How we pay non-generic medicines from the Above Threshold Benefit
You need to pay a co-payment when we pay non-generic medicines from the Above Threshold Benefit
You‘ll need to pay a co-payment of 10% of the Discovery Health Medication Rate to the pharmacy from your pocket when we pay non-generic medicines from the Above Threshold Benefit. This co-payment will apply even if the pharmacy charges below the Discovery Health Medication Rate.
We pay prescribed medicine up to a limit
A yearly limit applies to prescribed medicines (schedule 3 and above):
The following limits apply on the Executive Plan
| Single member | R19 300 |
| Member with one dependant | R22 550 |
| Member with two dependants | R25 850 |
| Member with three or more dependants | R29 100 |
These limits are pro-rated according to the number of months left in the year when you join.
Comprehensive Series
Prescribed medicine is paid from the day-to-day benefits
Discovery Health pays for prescribed medicines from the money available in your day-to-day benefits. This could be your Medical Savings Account or Above Threshold Benefit.
We pay medicines up to the Discovery Health Medication Rate. Claims for prescribed medicines (schedule 3 and above) count towards the yearly prescribed medicine limit.
We classify medicines into categories
The medicine categories are:
- generic medicines
- non-generic medicines
- over-the-counter and life-style enhancing medicines
- excluded items, like contact lens solutions etc.
A summary of how we pay prescribed medicines on your plan
| Type of medicine | How we pay the claim from your Medical Savings Account | How we pay the claim from the Above Threshold Benefit | How we add the claim to the Annual Threshold and annual limits |
|---|---|---|---|
| Generic medicine(schedule 3 and above) | Up to 100% of the Discovery Health Medication Rate | ||
| * Non-generic medicines (schedule 3 and above) | Up to 100% of the Discovery Health Medication Rate | Up to a maximum of 75% on the Discovery Health Medication Rate | |
| Over-the-counter medicine (schedule 0, 1 and 2) and certain lifestyle enhancing medicine (schedule 2 and above) | Up to 100% of the Discovery Health Medication Rate | Not covered | Does not add up |
| Exclusions | Not covered | Not covered | Not covered |
*For non-generic medicine where the claimed amount is less than 75% of the Discovery Health Medication Rate, 75% of the claimed amount will add up to the Annual Threshold and yearly prescribed medicine limit.
Please note this structure does not apply to medicine approved for payment from the Chronic Illness Benefit.
How we pay non-generic medicines from the Above Threshold Benefit
You need to pay a co-payment when we pay non-generic medicines from the Above Threshold Benefit
You‘ll need to pay a co-payment of 25% of the Discovery Health Medication Rate to the pharmacy from your pocket when we pay non-generic medicines from the Above Threshold Benefit. This co-payment will apply even if the pharmacy charges below the Discovery Health Medication Rate.
We pay prescribed medicine up to a limit
A yearly limit applies to prescribed medicines (schedule 3 and above). This limit is different depending on which Health Plan you are on and whether you are a single member or have dependants
Prescribed medicine limits for the year (including Delta network options)
| Series | Single member | Member with one dependant | Member with two dependants | Member with three or more dependants |
|---|---|---|---|---|
| Classic Comprehensive | R15 700 | R18 400 | R21 400 | R24 400 |
| Essential Comprehensive | R10 150 | R12 300 | R14 800 | R16 200 |
These limits are pro-rated according to the number of months left in the year when you join.
Priority Series
Prescribed medicine is paid from the day-to-day benefits
Discovery Health pays for prescribed medicines from the money available in your day-to-day benefits. This could be your Medical Savings Account or Above Threshold Benefit.
We pay medicines up to the Discovery Health Medication Rate. Claims for prescribed medicines (schedule 3 and above) count towards the yearly prescribed medicine limit.
We classify medicines into categories
We call the different medicine categories tiers.
The medicine categories are:
- generic medicines
- non-generic medicines
- over-the-counter and life-style enhancing medicines
- excluded items, like contact lens solutions etc.
A summary of how we pay prescribed medicines on your plan
| Type of medicine | How we pay the claim from your Medical Savings Account | How we pay the claim from the Above Threshold Benefit | How we add the claim to the Annual Threshold and annual limits |
|---|---|---|---|
| Generic medicine(schedule 3 and above) | Up to 100% of the Discovery Health Medication Rate | ||
| * Non-generic medicines (schedule 3 and above) | Up to 100% of the Discovery Health Medication Rate | Up to a maximum of 90% on the Discovery Health Medication Rate | |
| Over-the-counter medicine (schedule 0, 1 and 2) and certain lifestyle enhancing medicine (schedule 2 and above) | Up to 100% of the Discovery Health Medication Rate | Not covered | Does not add up |
| Exclusions | Not covered | Not covered | Not covered |
*For non-generic medicine where the claimed amount is less than 75% of the Discovery Health Medication Rate, 75% of the claimed amount will add up to the Annual Threshold and yearly prescribed medicine limit.
**On Priority Plans, we pay prescribed medicine up to the prescribed medicine benefit or the limited Above Threshold Benefit, whichever is reached first.
Please note: this structure does not apply to medicine approved for payment from the Chronic Illness Benefit.
How we pay non-generic medicines from the Above Threshold Benefit
You need to pay a co-payment when we pay non-generic medicines from the Above Threshold Benefit
You‘ll need to pay a co-payment of 25% of the Discovery Health Medication Rate to the pharmacy from your pocket when we pay non-generic medicines from the Above Threshold Benefit. This co-payment will apply even if the pharmacy charges below the Discovery Health Medication Rate.
We pay prescribed medicine up to a limit
A yearly limit applies to prescribed medicines (schedule 3 and above). This limit is different depending on which Health Plan you are on and whether you are a single member or have dependants
Prescribed medicine limits for the year
| Series | Single member | Member with one dependant | Member with two dependants | Member with three or more dependants |
|---|---|---|---|---|
| Classic | R10 150 | R12 300 | R14 800 | R16 200 |
| Essential | R7 250 | R8 550 | R10 150 | R12 300 |
Saver Series
Prescribed medicine is paid from the day-to-day benefits
Discovery Health pays for prescribed medicines from the money available Medical Savings Account.
We pay medicines up to the Discovery Health Medication Rate.
We classify medicines into categories
The medicine categories are:
- generic medicines
- non-generic medicines
- over-the-counter and life-style enhancing medicines
- excluded items, like contact lens solutions etc.
We pay prescribed medicine from your Medical Savings Account
We pay for medicine subject to funds available in your Medical Savings Account.
Core Series
KeyCare Series
Prescribed medicine is paid from the day-to-day benefits
KeyCare Plus
Prescribed medicines (according to the KeyCare acute medicine list) are covered only if prescribed or dispensed by your chosen KeyCare network GP
KeyCare Core
We do not pay for prescribed medicine on the KeyCare Core Plan because your plan does not have a day-to-day benefit.
