What is Covered by the Assisted Reproductive Therapy (ART) Bundle from Discovery
Assisted Reproductive Therapy (ART) is a range of medical procedures and infertility treatments to assist with conception. These include in vitro fertilisation (IVF), frozen embryo transfer (FET), intracytoplasmic sperm injection (ICSI) and intrauterine insemination (IUI).
Not all medical aids cover ARTs, with the notable exception of Discovery Health Medical Scheme – South Africa’s biggest medical scheme – and the most progressive in terms of covering to fertility treatment. Our Medfem Fertility Clinic team is proud to be a Discovery Designated Service Provider (DSP), and we are pleased to share in this article the details of the cover provided by Discovery’s ART basket of care.
Infertility can be the result of an extensive range of factors affecting both the female partner and the male partner. Female infertility factors may involve problems with ovulation, the reproductive organs, or hormones, to name just a few. Male infertility factors may involve abnormal sperm production or function, problems with sexual function, medication and even lifestyle choices.
The good news is that there are many safe and effective treatment options for almost all causes of infertility. Some of these treatments include lifestyle changes, medicine, surgery or assisted reproductive therapy, also known as ART.
Various therapies are often used together. In many couples, both partners require treatment, and in many cases, more than one treatment is required for each partner. In addition, certain treatments may need to be repeated.
The ART Basket of Care
Sadly, not all medical aids cover ARTs. However, since 2021 Discovery Health Medical Scheme members on the Executive and Comprehensive plans only have enjoyed access to its Assisted Reproductive Therapy (ART) Benefit.
This ART benefit gives members access to specific assisted reproductive therapy treatments, bundling the tests, consultations, treatments and medications required together.
Blood tests covered under the ART Bundle
In preparation to undergo any assisted reproductive therapy, your fertility specialist may require certain tests and these pathology tests will be paid from the Discovery (ART) Benefit if a healthcare professional at a SASREG accredited facility refer you for these tests, listed below.
* Hepatitis: Per antigen or antibody – 2 per year
* Grouping: A, B and O antigens – 1 per year
* Grouping: Rh antigen – 1 per year
* 17-OH progesterone – 1 per year
* DHEA sulphate – 1 per year
* Testosterone – 1 per year
* Anti-mullerian hormone – 1 per year (Only available to members 35 years and above)
Certain limits may apply and Discovery will pay these claims at a maximum of 75% of the Discovery Health Rate from the ART Benefit, subject to the overall R115 000 annual limit. Members will be responsible for any balance and any claims where the frequency or annual benefit limit has been reached.
Treatments covered under the ART Bundle
ART is a range of medical procedures and infertility treatments including in vitro fertilisation (IVF), frozen embryo transfer (FET), intracytoplasmic sperm injection (ICSI) and intrauterine insemination (IUI).
In addition, the comprehensive ART basket of care bundles cover for the consultations, ultrasounds, a defined list of pathology, egg retrieval, embryo transfer and freezing, admission costs and lab fees, medicine and embryo and sperm storage relating to the approved assisted reproductive therapy procedures.
Discovery covers per year up to two cycles of ART, including egg donated cycles, for patients between 25 and 39 years old; and one cycle for those from the age of 40 up to and including 42 years of age. If you are 43 years of age up to and including 50 years of age, Discovery will cover one egg donated IVF cycle per year, including the egg donor matching fee. The cost associated with egg donor agencies is not covered under the benefit and may result in a higher co-payment.
Members registered on the Oncology Programme who meet the Scheme’s clinical entry criteria, have access to cryopreservation and egg and sperm storage of up to five years.
Medicine covered under the ART Bundle
Where approved as part of your treatment, Discovery will pay for the medicine at 75% of the Discovery Health Rate, subject to the overall Discovery Health Rate for medicine associated with your treatment and the annual Assisted Reproductive Therapy Benefit limit.
Ideally, the accredited fertility clinic that you choose can dispense and bill the medical aid for the medicine that you need as part of your treatment.
Certainly at Medfem Fertility Clinic, conveniently located on our premises, you will find a dedicated pharmacy team at Medfem Fertility Clinic Pharmacy. Our team has worked with thousands of patients undergoing fertility treatment and specializes in meeting the unique needs of individuals with fertility challenges. The team of expert fertility pharmacists will always fill your order in person and are available to answer any questions, help you understand and manage side effects of the medications, ensure you are comfortable with your medication schedule and help you with the medical scheme claims.
The PMB Basket of Care
In addition to the benefits bundled under the Discovery ART basket of care, cover for certain other fertility tests, treatments and therapies related to the diagnosis, treatment and care of infertility are provided through Prescribed Minimum Benefits (PMBs), which all schemes must cover subject to a defined basket of care, regardless of a member’s chosen plan type.
Currently the defined basket of care under the Prescribed Minimum Benefit includes cover for the following:
* Blood tests (day3 FSH/LH, Oestradiol, Thyroid function, prolactin, rubella, HIV, VDRL, Chlamydia, D21 progesterone)
* Counselling and advice on sexual behaviour, temperature charts etc.
* Ovulation defects and deficiencies
* Semen analysis
* Surgery (uterus and tubal)
* Treatment of local infections
ART bundle criteria and guidelines
The Discovery ART Benefit provides cover for a defined list of procedures and treatments up to a Rand limit of R115 000 for each person, each year, subject to specific rules. Cover is up to 75% of the Discovery Health Rate when using an accredited facility in our network.
This means members have a co-payment of 25% of the costs for approved assisted reproductive therapy treatments. Any additional treatment needed before, during or after the therapy, or once the benefit limit has been reached, will be funded from the available day-to-day benefits or Prescribed Minimum Benefits (PMBs), where applicable and in accordance with your chosen health plan. Any costs incurred for procedures not currently listed under this benefit will not be covered by Discovery.
You can get the full details from Discovery by downloading their Discovery ART Benefit guide here.
Where to access your ART bundle
The Discovery ART Benefit is only available through healthcare providers that are listed as a Discovery Designated Service Provider (DSP), and that are also in the network of Southern African Society of Reproductive Medicine and Gynaecological Endoscopy (SASREG) accredited facilities, subject to clinical criteria, protocols and treatment guidelines.
Our Medfem Fertility Clinic team is proud to be a Discovery Designated Service Provider (DSP) and to be registered as an Accredited IVF (In-Vitro Fertilization) Unit with the Southern African Society for Reproductive Medicine and Gynaecological Endoscopy (SASREG).
During an initial consultation with a fertility specialist at Medfem Fertility Clinic, you can expect professional, reliable fertility tests that are interpreted by a qualified and experienced fertility specialist for an accurate diagnosis that leads to choosing the right treatment – as well as expert assistance in claiming the covered costs through your Discovery Medical Scheme cover.
Setting up your fertility consultation and tests at Medfem Fertility Clinic is as simple as clicking here or contacting us on +27 (11) 463 2244.
Our Fertility Specialists can also meet with You During a Virtual Consultation Via Zoom or Skype. Click here to book a virtual consultation now.
We look forward to meeting you!