Discovery Classic Smart vs Coastal Core - Breaking down all the differences

[airborne]

Well if you have gap cover the R12200 will be covered. So no limit on hospitals.

I forgot about that, I must look at mine.
Also the fact that Classic Smart will cover Ct/MRI scans out of hospital with a co-payment means the Gap cover may cover the co-payment and hence the scans will essentially be covered in full.

 

[Kosmik]

There's been a couple threads on this the last two months.

 

[Kosmik]

Then there's Essential Smart with the latter being R 800 cheaper still.

Something about sports injuries and 100% vs 200% cover which is anyway 1/3 of the bill and you have gap cover...

These cheaper plans are basically the same, they're covering the legislated PMBs at the cheapest cost (network hospital arrangements) and that's about it.

The add-ons are not worth very much if you think about it. R 80/month for medication you can save in your own stokvel.

A big difference with essential is price per member/dependent/child. As a family of four, more effective to go classic ( 2822+2227+1127+1127 = 7303/pm) vs essential ( 2021 * 4 = 8084/pm ) \essential dynamic( 1681 * 4 = 6724/pm ) . Higher care and more options for minimal increase. Keep in mind the co-payment rates are also higher on essential and half the hospital RMA costs ( 100% vs 200% ). Networks are also not the same.

 

[Kosmik]

I forgot about that, I must look at mine.
Also the fact that Classic Smart will cover Ct/MRI scans out of hospital with a co-payment means the Gap cover may cover the co-payment and hence the scans will essentially be covered in full.

Keep in mind Gap cover is capped annually as per legislation. So a person on a 100% plan will hit the limit quicker than someone on a 200% plan.

 

[Tomtomtom]

A big difference with essential is price per member/dependent/child.

Ah yes forgot that aspect. A lot of those cheaper plans are intended for young single people and this is how they do that targeting.

 

[airborne]

I just asked my broker and they say my Gap policy will cover the R3850 co-payment per MRI/CT scan and the R12200 co-payment if I use an out of network hospital for a planned admission, which makes moving to Classic Smart a no brainer.

An interesting point is because the Core plans don't offer any cover whatsoever for out of hospital MRI/CT scans you get zero cover for that from your Gap cover because you can only claim from Gap cover when you make a co-payment, for most things no co-payment means gap cover won't cover it.

 

[airborne]

My Sirago Gap Cover says this regarding the co-payment if I use an out of network hospital for a planned admission:

"Penalty Fee Co-payments: This benefit covers the penalty fee co-payment or deductible charged by your medical scheme for the voluntary use of a non-designated service provider/network hospital, or the use of a partial cover network hospital. We cover up to R16 000 (sixteen thousand rand) per claim, 2 (two) claims per policy per annum, irrespective of whether a rand amount or percentage penalty fee is charged by the medical scheme. Co-payments for administration charges are specifically excluded from cover on this policy."

This is the policy:

Ultimate Gap Cover – Sirago Underwriting Managers

www.sirago.co.za

 

[airborne]

I just noticed this cover that is included in the Classic Smart Plan:

Cover for defined acute medicine categories prescribed by a Smart Network GP. A limit of R1,905 a member a year and R3,180 a family a year for schedule 3 and above medicine, at a network pharmacy.
Would that include ADHD medication?

You also have cover for over-the-counter (OTC) medicine obtained from your network pharmacy, up to a limit of R835 per family per year.
Would things like Myprodol pain tablets be covered by that?

 

[airborne]

Google AI says this:

To claim for over-the-counter (OTC) medicine purchases on the Classic Smart Plan, you need to buy your medication from a MedXpress network pharmacy, as this is where you can access coverage for OTC medicine within your plan's yearly limit
simply present your medical aid card at the pharmacy when purchasing to have the claim processed automatically.

Key points to remember:
Network pharmacy:
Only purchase OTC medicine from a MedXpress network pharmacy to be eligible for claiming.

Limit on coverage:
Your Classic Smart plan will have a specific annual limit for OTC medicine, so be mindful of how much you spend.
No additional claims needed:
Usually, no further claim submission is required when buying from a MedXpress network pharmacy as the claim is processed automatically.

 

[saor]

@airborne Did you end up switching to Classic Smart? In the same boat now on Coastal Core and it would've been nice if some of the out of hospital MRI was covered. The R12 200 co-payment to use your preferred hospital doesn't bother me. Seems like a bit of a no-brainer to switch. Just need to dig into the details over the weekend to see if I'm missing anything as to what advantage coastal core has (if any).

 

[Kosmik]

@airborne Did you end up switching to Classic Smart? In the same boat now on Coastal Core and it would've been nice if some of the out of hospital MRI was covered. The R12 200 co-payment to use your preferred hospital doesn't bother me. Seems like a bit of a no-brainer to switch. Just need to dig into the details over the weekend to see if I'm missing anything as to what advantage coastal core has (if any).

Network, network, network.

First and foremost, check that.

 

[airborne]

@airborne Did you end up switching to Classic Smart? In the same boat now on Coastal Core and it would've been nice if some of the out of hospital MRI was covered. The R12 200 co-payment to use your preferred hospital doesn't bother me. Seems like a bit of a no-brainer to switch. Just need to dig into the details over the weekend to see if I'm missing anything as to what advantage coastal core has (if any).

Yes I did change and I’m loving the out of hospital benefits, unlimited R70 doctors visits that would normally cost R600, free eye test and basic dental checkup, R835 worth of OTC meds a year, some physio cover etc.

My gap cover with Sirago covers the co-payment for out of network hospital admissions.
If I recall correctly I couldn't find any difference with Costal Core other than the network hospital admissions but I think I went over the differences earlier in the thread.

 

[Kosmik]

Yes I did change and I’m loving the out of hospital benefits, unlimited R70 doctors visits that would normally cost R600, free eye test and basic dental checkup, R835 worth of OTC meds a year, some physio cover etc.

My gap cover with Sirago covers the co-payment for out of network hospital admissions.
If I recall correctly I couldn't find any difference with Costal Core other than the network hospital admissions but I think I went over the differences earlier in the thread.

Don't forget the acute, ie prescribed medicine benefit, its separate from the OTC.

 

[airborne]

Don't forget the acute, ie prescribed medicine benefit, its separate from the OTC.

Yes I discovered that, it doesn't cover any of that, I don't why if they are prepared to cover OTC meds then why not also allow you to use it for prescriptions. My ADHD meds were sadly also not covered by the "Cover for defined acute medicine categories prescribed by a Smart Network GP. A limit of R1,905 a member a year" - I don't know what that is supposed to be used for, things like antibiotics or similar?

 

[Kosmik]

Yes I discovered that, it doesn't cover any of that, I don't why if they are prepared to cover OTC meds then why not also allow you to use it for prescriptions. My ADHD meds were sadly also not covered by the "Cover for defined acute medicine categories prescribed by a Smart Network GP. A limit of R1,905 a member a year" - I don't know what that is supposed to be used for, things like antibiotics or similar?

Yes, its capped to prescribed s2/s3. Adhd meds are s6, not covered.

 

[airborne]

Yes, its capped to prescribed s2/s3. Adhd meds are s6, not covered.

What kind of things are s2/s3 schedule?
I rarely get sick so I'd like to find ways that I could potentially use the OTC and prescribed medicine benefit or it's all going to waste.

 

[Kosmik]

What kind of things are s2/s3 schedule?
I rarely get sick so I'd like to find ways that I could potentially use the OTC and prescribed medicine benefit or it's all going to waste.

Mainly the inbetween ones so stronger painkillers, anti biotics etc etc. Let me see if I can find the exact phrase

 

[Kosmik]

Cover for defined acute medicine categories prescribed by a Smart network GP. A limit of R1,905 a member a year and R3,180 a family a year for schedule 3 and above medicine, at a network pharmacy.

On the Classic Smart Plan you have cover for prescribed day-to-day medicine On the Classic Smart Plan, you have cover for affordable generic schedule three (3) and above medicine prescribed by your Smart Network GP, as long as it is obtained from a network pharmacy and not for medicine on the day-to-day medicine exclusion list. Where your Smart GP prescribes non-generic medicine, your pharmacist will suggest cost-efficient generic medicines that are equivalent (have the same effect as the original medicine). You do not have cover for medicine that is prescribed by a specialist or a non-network GP, or if the medicine falls within the exclusion list on page 3 below. Cover for acute medicine on the Classic Smart Plan is subject to an annual limit of R1,820 per person a year or R3,030 for a family for schedule 3 and above acute medicine prescribed by a Smart Network GP and obtained from a network pharmacy, which is any MedXpress Network Pharmacy.

Not sure what that defined list is but I always hand the script to the pharmacist and try cover it regardless.

https://www.discoveryhealthmedicalscheme.co.za/wcm/discoverycoza/assets/medical-aid/benefit-information/2024/how-we-pay-for-medicine-on-the-smart-series.pdf

 

[L-Dog]

FYI yesterday I bought medication from Dischem R 68 through medical aid and R 57 if you pay cash. Not sure if its the same for all or some medication but might often be better to leave the savings account for other items.

 

[Kosmik]

FYI yesterday I bought medication from Dischem R 68 through medical aid and R 57 if you pay cash. Not sure if its the same for all or some medication but might often be better to leave the savings account for other items.

Another trick is to pay cash and still claim. That way you get the cash benefit.

MSA's are just glorified savings pockets though. Unless your medical aid is actually paid for by someone else and not private OR CTC, it doesn't actually make sense depending. If you are on a ATB plan , differant story.