Your cover for medicine
Your cover for chronic medicine
The Chronic Illness Benefit covers you for a defined list of chronic conditions. You need to apply to have your medicine covered for your chronic condition.
Chronic conditions we cover on all plans
On all plans, you have access to a list of medical conditions and treatments under Prescribed Minimum Benefits (PMBs). The PMBs cover these 27 chronic conditions on the Chronic Disease List conditions:
Chronic Disease List (CDL) conditions
Addison’s disease, Asthma | Bipolar mood disorder, Bronchiectasis| Cardiac failure, Cardiomyopathy, Chronic obstructive pulmonary disease (COPD), Chronic renal disease, Coronary artery disease, Crohn’s disease| Diabetes insipidus, Diabetes type 1, Diabetes type 2, Dysrhythmia| Epilepsy | Glaucoma | Haemophilia, HIV, Hyperlipidaemia, Hypertension, Hypothyroidism | Multiple sclerosis| Parkinson’s disease | Rheumatoid arthritis | Schizophrenia, Systemic lupus erythematosus | Ulcerative colitis
To access PMB cover, you need to meet certain terms and conditions.
Your medicine cover for the Chronic Disease list conditions
You get full cover for approved chronic medicine on our medicine list. For medicine not on our list, we cover you up to a set monthly rand amount called the Chronic Drug Amount. The Chronic Drug Amount does not apply to the Smart Plan and KeyCare plans – you will have to pay for medicine that is not on the medicine list.
Chronic conditions we cover on the Executive and Comprehensive plans
On the Executive and Comprehensive plans, you also get cover for medicine for a defined list of conditions on the Additional Disease List. You can use up to the set monthly Chronic Drug Amount for your medicine. No medicine list applies.
Additional Disease List (ADL) conditions
Ankylosing spondylitis| Behcet’s disease |Cystic fibrosis | Delusional disorder, Dermatopolymyositis |Generalised anxiety disorder| Huntington’s disease | Isolated growth hormone deficiency | Major depression, Muscular dystrophy and other inherited myopathies, Myasthenia gravis | Obsessive compulsive disorder, Osteoporosis | Motor neuron disease | Paget’s disease, Panic disorder, Polyarteritis nodosa, Post traumatic stress disorder, Psoriatic arthritis, Pulmonary intestinal fibrosis | Sjögren’s syndrome, Systemic sclerosis | Wegener’s granulomatosis
To access cover for these additional conditions, you need to meet certain terms and conditions.
Additional documents on your cover for chronic medicine
Your cover for acute or day-to-day prescribed medicine
You have cover for prescribed acute medicine from your available day-to-day benefits.
Acute medicine is medicine that is prescribed for a short term for a condition or illness that is not long lasting.
On Smart Plan you get cover for a defined list of acute medicine with a R10 co-payment for each medicine item when prescribed by your network GP. This is limited to 12 prescriptions a person a year. You need to collect your medicine from your network pharmacy.
On the Executive, Comprehensive and Priority plans, your cover is also subject to the annual limit for prescribed medicines.
Depending on the scheduling status of the medicine your doctor prescribes, and whether it is a generic or original brand product, we pay for these differently.
The Medicines Control Council applies standards laid down by the Medicines and Related Substances Act, (Act 101 of 1965) which governs the manufacture, distribution, sale, and marketing of medicines. The prescribing and dispensing of medicines is controlled through the determination of schedules for various medicines and substances.
In South Africa, a doctor must prescribe medicine with a scheduling status of 3 and above. This means you cannot get these medicines without a doctor’s prescription.
Medicines that are schedule 0, 1 and 2 are called over-the-counter medicines and while your doctor may prescribe these, you can also get these without a prescription.
Generic medicine has the same active ingredient/s, strength and form as the original/brand medicine. This refers to medicine where patent protection has expired or where a patent has never been issued. Non-generic medicine refers to brand-name original medicine that is or has been previously protected by a patent.
Generic medicine (schedule 3 and above)
We pay the claims up to 100% of the Discovery Health Rate for medicines from your Medical Savings Account and Above Threshold Benefit. We add up 100% of the Discovery Health Rate for medicines towards your Annual Threshold and the annual prescribed medicine limit.
Non-generic medicine (schedule 3 and above)
We pay the claims up to 100% of the Discovery Health Rate for medicines from your Medical Savings Account.
If you are on the Executive Plan, we pay up to 90% of the Discovery Health Rate for medicine from your Above Threshold Benefit and add up 90% of the Discovery Health Rate for medicine towards your Annual Threshold and the annual prescribed medicine limit.
On the Comprehensive and Priority plans, we pay the claims up to 100% of the Discovery Health Rate for medicines from your Medical Savings Account. We pay up to 75% of the Discovery Health Rate for medicine from your Above Threshold Benefit and add up 75% of the Discovery Health Rate for medicine towards your Annual Threshold and the annual prescribed medicine limit.
Over-the-counter medicines (schedule 0, 1 and 2) and certain lifestyle-enhancing medicine
We pay the claims up to 100% of the Discovery Health Rate for medicines from your Medical Savings Account. We do not pay for over-the-counter medicines from your Above Threshold Benefit. We do not add up the claim towards your Annual Threshold or the annual prescribed medicine limit.
We pay prescribed medicine up to a limit
An annual limit applies to prescribed medicines (schedule 3 and above). If you join the medical scheme after January, you will not get the full limit as we calculate the amount by counting the remaining months in the year.
Members on the Executive, Classic Comprehensive and Classic Delta Comprehensive plans have extended medicine cover
On the Executive, Classic Comprehensive and Classic Delta Comprehensive plans, we extend cover for generic medicine through the Insured Network Benefit when you have used up your annual Medical Savings Account allocation and have not yet reached your Annual Threshold.
Choose preferentially priced medicine for value for money
As a Discovery Health Medical Scheme member, you can choose preferentially priced medicine for value for money. We have developed a list of preferred medicines that will offer you real value for your money, because we cover them in full up to the Discovery Health Rate for medicines under certain conditions.
We encourage the use of generic medicines that are included in our Preferred Medicine List. Your pharmacist or doctor is the best person to tell you about the benefits of substituting your prescribed item with a more preferentially priced (normally a generic) medicine where appropriate.
To find out how your medicine will be covered, go to the MedAdvisor tool.
Where to get your medicine for full cover
If you need to use a designated service provider
To avoid a 20% co-payment, you have to use these designated service providers:
For Smart Series and KeyCare Plans you have to use these designated service providers for cover. If you don’t, you will have to pay the full account.
|Smart Series:||MedXpress, Clicks, or Dis-Chem|
|KeyCare plans:||You must use a network pharmacy or your allocated GP.|
Use one of over 2 400 pharmacies in our network
On other plans, you can use a pharmacy in our network that has agreed to charge no more than the Discovery Health Rate for medicines.
Get your monthly medicine by using Discovery MedXpress, an ordering service that delivers or allows in-store collection.
Find out how your medicine will be covered
To find out how your medicine will be covered, go to the MedAdvisor tool.