Flexicare (powered by Discovery)

Flexicare Core

• Four direct face-to-face visits to your allocated network GP. Beyond four, further visits are available only through a nurse referral or through the Intercare Online Platform.
• Preauthorisation is required from the third visit. On a four-visit benefit, that means half of your direct visits need authorisation first.
• A face-to-face visit is also covered when the virtual GP refers you during a primary care clinic visit, and when a virtual GP consultation on the Intercare Online Platform leads to a face-to-face referral.
• Two primary care clinic nurse consultations a year. Authorisation is needed after the second. The nurse can consult a virtual GP during the visit and can dispense medicine.
• Virtual GP consultations through the Discovery website, with a network GP, without a nurse referral.

Flexicare Plus

• Unlimited face-to-face visits to a network GP, and unlimited virtual consultations. You may substitute a face-to-face visit with a virtual one.
• No nurse consultation benefit. This is the one benefit Core has and Plus does not.

On both tiers you are allocated one network GP and may change that allocation twice a year. A consultation with any other doctor is not covered at all.

Flexicare Core has no specialist cover. Flexicare Plus covers one out-of-hospital specialist consultation per member per year, with a total benefit limit of R2 090. The limit is the whole benefit, not a per-item allowance.

• Network specialist: covered to R1 465, made up of a R1 360 consultation fee and R105 for a SOAP note for a referral where one is needed.
• Radiology or pathology after that consultation: R625, which accumulates against the same R2 090 limit. R1 465 plus R625 is exactly R2 090, so the benefit is fully spent by one consultation and one round of tests.
• Non-network specialist: paid up to 100% of the Discovery Health Rate, and you carry the difference. You must pay the specialist and the radiology or pathology out of your own pocket at the time and submit the claim to Discovery for reimbursement afterwards.
• If the treatment costs more than the limit, the difference is yours.

Acute medicine

Covered at 100% of the Agreed Rate on both tiers, unlimited on Plus, subject to four conditions on both: it must be prescribed or dispensed by a network GP (on Core, also by the nurse at a primary care clinic visit), it must be on the acute medicine formulary, it must come from a dispensing network GP or a network pharmacy, and there is no co-payment if all of that holds. Medicine prescribed by a non-network doctor or nurse, or obtained from a non-network pharmacy, is not covered.

Over-the-counter medicine

Only at a network pharmacy, only on the pharmacist's advice, and only from the formulary. The limits are the sharpest difference between the two tiers, and note the different basis:

On Core the R170 is shared by the whole family. A couple with two children has R170 between four people for the year, and R85 of that cannot be spent before the second half of the year. On Plus each member has their own R480.

Chronic medicine

Covered in full at 100% of the Agreed Rate when the prescribed medicine is on the chronic formulary and is collected from a network pharmacy. There is a 12-month waiting period on chronic conditions, and a 12-month condition-specific waiting period may be applied to anything that existed before your start date.

Flexicare Core covers these conditions: asthma, diabetes insipidus, diabetes mellitus type 1, diabetes mellitus type 2, hyperlipidaemia, hypertension and HIV. The brochure heads this list as six conditions and then prints seven items. HIV is separately funded through the HIV Programme, which probably explains it, but the source contradicts itself and you should get the definitive list in writing.

Flexicare Plus covers 27 conditions: Addison's disease, asthma, bipolar mood disorder, bronchiectasis, cardiac failure, cardiomyopathy, chronic renal disease, chronic obstructive pulmonary disease, coronary artery disease, Crohn's disease, diabetes insipidus, diabetes mellitus type 1, diabetes mellitus type 2, dysrhythmias, epilepsy, glaucoma, haemophilia, HIV, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson's disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus and ulcerative colitis.

The formulary itself is not published. Neither is what happens if your medicine is not on it: the brochure says only that formulary medicine is available without a co-payment.

Flexicare Core has no dentistry benefit. On Flexicare Plus the benefit exists only at a network dentist, and carries a three-month waiting period.

• Consultation: one full mouth examination for each member every year.
• Preventive treatment: one cleaning, scaling and polishing for each member every year.
• Restorations: up to three fillings a member a year.
• Extractions: one single tooth extraction per quadrant per 365 days, plus one additional tooth in the same quadrant per member per 365 days.
• Oral radiography: up to seven a year, according to dental protocol.
• Also included: diagnosis and treatment of pain and sepsis, infection control, oral hygiene advice and local anaesthetic.

Specialised dentistry is excluded. That means no crowns, bridges, implants, root canal treatment, surgical extractions, dentures, orthodontics or gold fillings. This exclusion list is from a broker mirror of the Flexicare material rather than the 2026 brochure, which does not publish a dental exclusion list, so confirm it in writing.

Flexicare Core has no optometry benefit. On Flexicare Plus the benefit is available at a network optometrist only, and carries a three-month waiting period.

• Eye examination: one for each member every year, including a visual evaluation, screening and diagnosis.
• Spectacles and lenses: one pair for each member in a 24-month period. Standard, high-quality clear plastic lenses, single-vision or bi-focal. Qualifying norms apply and are not published.
• Frames: one frame for each member in a 24-month period, fully covered from an approved selection. Choose a frame outside that selection and you pay the extra cost.
• Contact lenses are excluded. The brochure states the benefit is spectacles only.

Radiology, both tiers

Unlimited access to black-and-white X-rays and soft-tissue ultrasounds on a list of approved codes, at 100% of the Agreed Rate. A network GP must request the test and you take the request form to the radiologist yourself. The approved code list is not published. There is no MRI or CT benefit on either tier.

Pathology, both tiers

Blood tests limited to a list of approved pathology codes, paid at 100% of the Agreed Rate, requested by a network GP and performed by a network pathologist. The approved code list is not published. Radiology and pathology carry a one-month waiting period.

Procedures in the doctor's rooms

Both tiers cover a defined list of procedures done in a network GP's rooms. On Core the brochure restricts this to the doctor's rooms only. The published code list includes intravenous treatment and infusions, repair of a nail bed, drainage of an abscess, removal of a foreign body, stitching of additional wounds, excision and repair, fine needle aspiration, aspiration of a cyst or tumour, biopsy or excision of a cyst or benign tumour, a limb cast excluding aftercare, removal of foreign bodies requiring incision, nebulisation in rooms, peak expiratory flow, several forms of electrocardiogram including effort and treadmill tests, bladder catheterisation, three forms of circumcision, and the two routine obstetric ultrasounds at 10 to 20 weeks and 20 to 24 weeks.

Anything outside that list, or done anywhere but a network provider, is yours to pay in full.

Maternity, both tiers

The maternity benefit carries a 12-month waiting period, which in practice means you must have held the policy for a year before conception is useful to you. On Core the benefit applies only when a network GP refers you. On Plus there is no referral condition. Both tiers then cover the same things:

• Unlimited network doctor visits throughout the pregnancy.
• Unlimited acute medicine from the defined medicine list, prescribed or dispensed by a network doctor and collected from a network pharmacy.
• Essential blood and screening tests through a network pathologist on referral from a network doctor.
• Two ultrasound scans for each pregnancy at a network provider, the first between week 10 and week 14 and the second between week 20 and week 24.

The delivery itself is not covered. Flexicare pays for the pregnancy, not the birth. A normal delivery in a private hospital, a caesarean section, an epidural, the paediatrician, the neonatal unit and the hospital account are all yours. Emergency Max covers ectopic pregnancy, which is a different thing entirely. On a registered medical scheme, delivery is a Prescribed Minimum Benefit.

HIV Programme, both tiers

Unlimited HIV medicine from the date your network GP registers your chronic medicine, after a 12-month waiting period. The programme covers voluntary counselling and testing, antiretroviral therapy, prophylactic antibiotics and supplements, treatment support and guidance, and pathology monitoring including CD4, viral load, liver enzymes, cholesterol, glucose and urine tests, according to protocol. Emergency post-exposure medicine is provided if the accidental exposure is reported to the network GP within 72 hours. All HIV queries are handled confidentially through a dedicated address.

COVID-19

For a confirmed positive result, both tiers cover one positive COVID-19 test with access to out-of-hospital management and supportive treatment, including diagnostic testing, a basic chest X-ray and prescribed medicine. On Core this applies only on referral by a network GP.

Screening and prevention, both tiers

• One flu vaccination a year from a network pharmacy.
• One wellness screening a year at a network pharmacy or wellness day, covering blood pressure, blood glucose, cholesterol and body mass index, with an optional HIV test at the same visit. You receive a summary of the results afterwards.

The FlexiFund

The FlexiFund is a pot of benefit money you unlock by doing the health check. It pays automatically for an active adult or child member's claims when there are no day-to-day benefits left, and it may be spent on GP consultations, specialist visits, over-the-counter medicine, prescribed medicine, vaccines and contraceptives.

The amount depends on how many of five health check metrics fall inside the healthy range. The five are weight status, blood pressure, blood glucose, cholesterol and smoking status.

Emergency Cover is a separate non-life insurance policy underwritten by Discovery Insure Ltd. It is the only route to any in-hospital rand on a Flexicare policy, and it is a defined-event, capped policy. It is not hospital cover in the medical scheme sense.

The accidents Emergency Core covers

Burns. Head injuries, chest injuries or severe fractures resulting from a fall. Loss of an arm, hand, leg or foot. Near-drowning. Poisoning or a serious allergic reaction that may cause death. Injuries resulting from a crime, a sexual assault, a car accident or an injury at work. That is the list. A heart attack, an appendix, a stroke or a burst ulcer is not an accident and Emergency Core does not cover it.

The nine conditions only Emergency Max covers in hospital

Acute appendicitis, acute asthma, ectopic pregnancy, acute inflammation of the gall bladder, a fit or seizure, acute pneumonia, kidney stones, acute renal failure and pulmonary embolism. These nine carry a R400 000 sub-limit even on the R1 million policy.

Support benefits, all three levels

Medical evacuation, counselling sessions, take-home medicine and a premium waiver. The terms and limits attached to each are not published in the 2026 brochure.

This list is the reason to read the whole page. None of the following is covered on either tier, at any price, with or without Emergency Cover, unless it happens to fall inside one of the defined emergency events above.

• Any planned or elective hospital admission.
• Any surgery other than the defined minor procedures in a network GP's rooms.
• Cancer: diagnosis, chemotherapy, radiotherapy, surgery and oncology medicine.
• Childbirth, whether normal delivery or caesarean section, and neonatal care.
• MRI and CT scans, in or out of hospital.
• Physiotherapy, psychology, psychiatry and any mental health admission.
• Prosthetics, joint replacements, hearing aids and external medical appliances.
• Dialysis and organ transplants.
• Specialised dentistry: crowns, bridges, implants, root canals, dentures and orthodontics.
• Contact lenses.
• Anything from a provider outside the Flexicare network.
• Anything not on the applicable formulary or approved code list.
• Prescribed Minimum Benefits, because the product has none.

The 2026 brochure does not publish a general exclusions clause. The list above is assembled from what the benefit tables do and do not include, plus the exclusions named in broker mirrors of the Flexicare material. Ask for the full policy wording before you sign: it is not publicly downloadable, and cancellation, cooling-off and claim repudiation terms are not published in any brochure.

A waiting period means you and your dependants cannot claim for that service during the period. The 2026 brochure publishes them, which is more than most medical schemes do.

• Newborns join free of waiting periods if you add them to the policy within 90 days of birth.
• A break of more than 30 days restarts everything. If you or a dependant lapse for more than 30 days, every waiting period is applied again when you reapply.
• Read the condition-specific waiting period alongside the fact that this is insurance and not a scheme. A medical scheme cannot refuse you and cannot price you on your health. An insurer can underwrite. If you have a pre-existing chronic condition, the practical effect is that you pay for a year before the chronic benefit does anything for you.

A three-month general waiting period for a dependant who joins 60 or more days after the main member appears in the Flexicare employer guide rather than the retail brochure. Confirm which applies to your policy.

• The minimum age for a principal member is 18. There is no maximum age, and no age limit on dependants. This is from discovery.co.za, not from the brochure.
• There is no limit on the number of children and each child is charged separately. From the month after a 21st birthday, the adult dependant premium applies.
• An application received by the 10th of a month activates on the 1st of the following month. Later applications start two months later. This joining rule comes from a broker mirror of the Flexicare material.
• You get a digital membership card by WhatsApp on enrolment and a physical card afterwards.
• You may not hold Flexicare and medical scheme membership at the same time. Discovery states this on its own product pages. It is an either-or decision, not a top-up.
• Flexicare may not be used for a visa application. Discovery says so directly: it is a South African health insurance product and is not appropriate for visa purposes.
• Discovery confirms premiums changed on 1 January 2026 but places the percentage behind a member login, so the 2026 increase is not published.

• You normally pay nothing at the point of care. Network providers submit claims electronically and GP consultations are paid by capitation, so a network GP visit should cost you nothing on the day.
• The exception is a specialist. On Flexicare Plus you pay the specialist and any radiology or pathology yourself at the time and claim it back from Discovery afterwards.
• Cash claims should be submitted with receipts. A four-month submission deadline appears in a broker mirror of the Flexicare material and not in the 2026 brochure. Confirm the deadline before you rely on it.
• Pre-authorisation on Core is needed from the third GP visit, and after the second nurse consultation.
• Hospital pre-authorisation runs on 0860 44 47 79. The brochure lists this line even though the base product has no hospital benefit. It exists for admissions under the optional Emergency Cover.
• After hours emergencies go to the same number. If you have activated Emergency Cover and call after hours, the call is diverted to Netcare 911.

This is the most commonly misunderstood consequence of buying insurance instead of scheme membership. The Council for Medical Schemes has no jurisdiction over Flexicare. A member who lodges a Flexicare complaint with the Council will be turned away, because the Council regulates medical schemes under the Medical Schemes Act and Flexicare is a non-life insurance policy.

The internal route, as Discovery publishes it

1. The Flexicare call centre on 0860 44 47 79, or flexicare@discovery.co.za.
2. Escalations to flexicareescalations@discovery.co.za.
3. Discovery Group Compliance at compliance@discovery.co.za if you still have concerns.

The external route, which Flexicare does not name

The 2026 brochure stops at Group Compliance and names no external ombud at all. That is a genuine disclosure gap on a product sold to people who may not know the difference between a scheme and a policy. Based on how the product is licensed, these are the statutory forums:

• National Financial Ombud Scheme South Africa, non-life insurance division, for a dispute about the policy, a claim or a benefit against Auto and General Insurance Company Limited or Discovery Insure Ltd. Phone 0860 800 900 or email info@nfosa.co.za. The NFO absorbed the former Ombudsman for Short-Term Insurance in 2024.
• The FAIS Ombud, for a complaint about the advice you were given or the conduct of the adviser or provider who sold you the policy. Phone 012 762 5000 or 086 066 3274, email info@faisombud.co.za, or write to PO Box 41, Menlyn Park, 0063.
• The Financial Sector Conduct Authority as the market conduct regulator, and the Prudential Authority for insurer solvency.

The ombud contact details above come from nfosa.co.za, the Ombud Council and faisombud.co.za, checked on 9 September 2026. They are not printed in any Flexicare document. The routing itself follows from the product's licensing rather than from a Discovery instruction.

No. Discovery states in the legal footer of every Flexicare document that Flexicare is not a medical scheme, that the cover is not the same as a medical scheme's, and that it is not intended to be a substitute for medical scheme membership. It is a non-life insurance policy underwritten by Auto and General Insurance Company Limited and administered by Discovery Health. It has no Prescribed Minimum Benefits, no hospital cover and no protection under the Medical Schemes Act.

You pay the account. The base product covers out-of-hospital care only. If you have bought the optional Discovery Emergency Cover, it may pay for a defined accident or a defined emergency up to R400 000 or R1 million, with a R200 or R250 co-payment on the Plus and Max levels. Emergency Core covers accidents and trauma only. Emergency Plus adds admission for a confirmed heart attack or stroke. Emergency Max adds nine further conditions with their own R400 000 sub-limit. A planned admission, an operation, cancer treatment or a birth is not covered on any of them.

R80 a month for a principal member, and a great deal of cover. Plus gives unlimited face-to-face GP visits instead of four, one specialist consultation a year capped at R2 090 instead of none, dentistry at a network dentist, an eye test and spectacles at a network optometrist, 27 chronic conditions instead of six, R480 a member a year of over-the-counter medicine instead of R170 for the whole policy, and a FlexiFund of up to R1 000 instead of R500. Core gives one thing Plus does not: two nurse consultations a year.

Four direct face-to-face visits a year, and preauthorisation is required from the third of those. After the four, further face-to-face visits are available only when a nurse refers you or when a virtual GP on the Intercare Online Platform refers you. Virtual consultations are separate and do not need a nurse referral. If you see general Flexicare advertising that says unlimited GP consultations, that describes Flexicare Plus, not Core.

No. There is no oncology benefit on either tier, cancer is not on either chronic medicine list, and Discovery Emergency Cover covers defined accidents and a defined list of emergency conditions that does not include cancer. A member diagnosed with cancer on Flexicare has no cover for the diagnosis, the surgery, the chemotherapy, the radiotherapy or the medicine. On a registered medical scheme, cancer treatment is covered at least to the Prescribed Minimum Benefit level on every option the scheme sells.

It covers the pregnancy, not the birth. The maternity benefit gives unlimited network doctor visits through the pregnancy, unlimited formulary acute medicine, essential blood and screening tests, and two ultrasound scans, one between weeks 10 and 14 and one between weeks 20 and 24. The delivery itself, the hospital account, the caesarean section, the epidural, the paediatrician and any neonatal care are not covered. The maternity benefit also carries a 12-month waiting period, so it is only useful to someone who has held the policy for a year before conceiving.

No. Discovery states on its own product pages that Flexicare cannot be held alongside medical scheme membership, and its employer material says the same to employees. So this is not a top-up you add to a hospital plan to cover day-to-day costs. It is an alternative to scheme membership, and choosing it means giving up Prescribed Minimum Benefits entirely.

It is a pot of benefit money unlocked by an annual health check, spendable on GP consultations, specialist visits, over-the-counter and prescribed medicine, vaccines and contraceptives, and paid out automatically when your day-to-day benefits are exhausted. The amount depends on how many of five metrics fall in the healthy range: weight status, blood pressure, blood glucose, cholesterol and smoking status. Five in range pays R500 on Core and R1 000 on Plus. Two or fewer pays R125 and R250. There is a three-month waiting period. The brochure also contradicts itself on whether each adult has a fund or the policy has one fund unlocked by the first adult's health check, so ask which applies to your policy.

One out-of-hospital consultation a member a year, with a total limit of R2 090. At a network specialist that is R1 465 for the consultation and a referral note, plus R625 for radiology or pathology referred from that consultation. Those two add up to exactly the R2 090 limit, so one visit and one round of tests exhausts it. A non-network specialist is paid to 100% of the Discovery Health Rate and you carry the shortfall, and you must pay upfront and claim back. If you use the benefit on a first specialist and are not referred for tests, a second specialist visit later in the year is not funded at all.

You pay the whole bill. There is no partial payment and no percentage of a tariff for a non-network GP, pharmacy, dentist, optometrist or pathologist. You are allocated one network GP at a time and you may change that allocation twice a year. The single exception is a non-network specialist on Flexicare Plus, which is paid up to 100% of the Discovery Health Rate with the difference for your account.

One month general, and one month on radiology, pathology, over-the-counter medicine and the Emergency Cover trauma benefit. Three months on dentistry, optometry and the FlexiFund. Twelve months on maternity, HIV and chronic conditions. A 12-month condition-specific waiting period may be applied to any condition, chronic illness or HIV that existed before your start date. Newborns added within 90 days of birth serve no waiting periods. If your cover lapses for more than 30 days, every waiting period starts again.

Not the Council for Medical Schemes. The Council regulates medical schemes and has no jurisdiction over an insurance policy. Start with the Flexicare call centre on 0860 44 47 79 or flexicare@discovery.co.za, escalate to flexicareescalations@discovery.co.za, then to Discovery Group Compliance at compliance@discovery.co.za. Beyond that, Flexicare's own documents name no external ombud, which is a real gap. The correct external forums for a product licensed this way are the National Financial Ombud Scheme South Africa on 0860 800 900 for the policy and the claim, and the FAIS Ombud on 012 762 5000 for the advice you were given.