Focus on the Evolve Option - 2025

Introduction

The Evolve Option provides cover for hospitalisation at the Evolve Network of private hospitals. There is no overall annual limit for hospitalisation. There is a standard Evolve Option co-payment for all Major Medical Benefits including non-emergency Prescribed Minimum Benefits, except in the case of motor vehicle accidents, maternity confinements or emergency treatment. 

You need to use State facilities for all your chronic treatment, including doctors, scripts and medication. 

You have cover for two virtual GP consultations from the GP Virtual Consultation Network, which includes Hello Doctor+. The Health Platform provides cover for a range of day-to-day benefits, such as preventative screening tests, certain check-ups and more. If you need cover for more day-to-day expenses, like additional GP visits or prescribed medicine, you can make use of Momentum HealthSaver+HealthSaver is a complementary product offered by Momentum that lets you save for medical expenses not covered on your option. 

Momentum Medical Scheme’s 2025 benefit and contribution amendments have been submitted to the Council for Medical Schemes and are subject to approval by the Regulator. 

This focus page summarises the 2025 benefits available on the Evolve Option. Scheme Rules always take precedence and are available on request.

Major Medical Benefit

Provider Evolve Network hospitals. Certain procedures are only covered in day hospitals. The list of day hospitals is available on theMomentum App or momentummedicalscheme.co.za. You can download the app from the Play Store, App Store orAppGallery
Limit No overall annual limit applies
Rate Associated specialists are covered in full. Other specialists covered up to 100% of the Momentum Medical Scheme Rate. Hospital accounts are covered in full at the rate agreed upon with the hospital group
Specialised procedures/treatment Certain procedures/treatments covered, refer to Focus on specialised procedures/treatment
Co-payments R1 920 per authorisation including non-emergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements and emergency treatment and when you involuntarily use a non-Designated Service Provider. An additional co-payment may apply for certain specialised procedures/treatment, refer to Focus on co-payment

This benefit includes cover for hospitalisation and certain specialised procedures/treatment. There is no overall annual limit on hospitalisation. Claims are paid up to 100% of the Momentum Medical Scheme Rate. Under the hospitalisation benefit, hospital accounts and related costs incurred in hospital (from admission to discharge) are covered – provided that treatment has been authorised. Specialised procedures/treatment do not necessarily require admission to hospital and are included in the Major Medical Benefit – provided that the treatment is clinically appropriate and has been authorised.

A co-payment of R1 920 per authorisation applies to Major Medical Benefits including for non-emergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements, emergency treatment and when you involuntarily use a non-designated Service Provider. An additional co-payment may apply for certain specialised procedures. 

If pre-authorisation is not obtained, a 30% co-payment will apply on all accounts related to the event and the Scheme would be responsible for 70% of the negotiated tariff, provided authorisation would have been granted according to the Rules of the Scheme. In the case of an emergency, you or someone in your family or a friend must obtain authorisation within 72 hours of admission. Some procedures are only covered in day hospitals, such as cataract surgery and some sinus procedures – here is the List of procedures covered in any day facility on the Evolve Option only.


Chronic Benefit

Chronic provider and formulary State facilities and State formulary
Chronic conditions covered 26 conditions covered according to the Chronic Disease List in the Prescribed Minimum Benefits

The Chronic Benefit covers certain life-threatening conditions that need ongoing treatment. On the Evolve Option, chronic benefits are available from State facilities only. Chronic cover is provided for 26 conditions according to the Chronic Disease List, which forms part of the Prescribed Minimum Benefits. Chronic benefits are subject to registration and approval by the Scheme.


Day-to-day Benefit

Day-to-day provider Any provider
Day-to-day benefit

2 virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. 2 physiotherapist or biokineticist consultations per beneficiary for sports injuries, up to R1 120 per year. You can add HealthSaver to provide cover for your day-to-day healthcare expenses, such as additional GP visits and prescribed medicine

You have cover for two virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. If you need cover for other day-to-day expenses, like GP visits or prescribed medicine, you can choose to make use of Momentum HealthSaver. HealthSaver is a complementary product offered by Momentum that lets you save for medical expenses not covered by your option.


Health Platform Benefit

Provider Any provider

Health Platform Benefits are paid by the Scheme up to a maximum rand amount per benefit, provided you notify us before using certain benefits. This unique benefit encourages health awareness, enhances the quality of life and gives peace of mind through:

  • preventative care and early detection;
  • maternity programme; and
  • health education and advice.

Contributions

Maximum of 3 children charged for


Benefit Schedule

Major Medical Benefit

Major Medical Benefit 
General rule applicable to the Major Medical Benefit: You need to contact us for pre-authorisation before making use of your Major Medical Benefits. For some conditions, like cancer, you will need to register on a health management programme. The Scheme will pay benefits in line with the Scheme Rules and the clinical protocols that the Scheme has established for the treatment of each condition. The sub-limits specified below apply per year. Should you not join in January, your sub-limits will be adjusted pro-rata (this means it will be adjusted in line with the number of months left in the year). 
Provider  Evolve Network hospitals. Certain procedures are only covered in day hospitals. See a list of these procedures here. The list of day hospitals is available on the Momentum App. You can download the app from the Play Store, App Store or AppGallery
Overall annual limit  None 
Co-payments R1 920 per authorisation including non-emergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements and emergency treatment An additional co-payment may apply for specialised procedures, as indicated below.
Co-payments for specialised procedures/treatment
The standard Evolve Option co-payment of R1 920 per authorisation applies to these procedures and treatment regardless of where they are performed. Plus the specialised procedures/treatment co-payment of R3 840 per authorisation applies if performed in an acute or day hospital
Arthroscopies, Back and neck surgery*, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements*, Laparoscopies Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above
Gastroscopies, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, Removing of extensive skin lesions Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above
Conservative back and neck treatment*, Removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections Low severity cases are not covered by the Scheme but can be paid from Momentum HealthSaver, if available

High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above
* Covered at State facilities
Hospitalisation 
Benefit  Associated specialists are covered in full. Other specialists are covered up to 100% of the Momentum Medical Scheme Rate. Hospital accounts are covered in full at the rate agreed upon with the hospital group
High and intensive care  No annual limit applies
Casualty or after-hour visits Subject to Momentum HealthSaver, if available
Renal dialysis Limited to Prescribed Minimum Benefits at State facilities
Oncology R200 000 per beneficiary per year, thereafter a 20% co-payment applies. Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medication. You need to get your oncology treatment and medication from the Evolve Network of Oncologists
Organ transplants  Limited to Prescribed Minimum Benefits at State facilities
In-hospital dental and oral benefits  Not covered. Maxillo-facial trauma covered at State facilities, limited to Prescribed Minimum Benefits
Maternity confinements  No annual limit applies 
Neonatal intensive care  No annual limit applies 
Medical and surgical appliances in hospital (such as support stockings, knee and back braces, etc.)  R7 530 per family 
Prosthesis – internal (incl. permanent pacemakers, cochlear implants, etc). Joint replacements, including knee and hip surgery, are limited to Prescribed Minimum Benefits at State facilities Intraocular lenses: R6 300 per beneficiary per event,
maximum 2 events per year
Other internal prosthesis: R42 000 per beneficiary per event, maximum 2 events per year
Prosthesis – external (such as artificial arms or legs)  R27 000 per family
MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans  No annual limit applies, subject to co-payment of R3 200 per scan
Mental health  
  • incl. psychiatry and psychology 
  • drug and alcohol rehabilitation 
Limited to Prescribed Minimum Benefits at Evolve Network hospitals
Take-home medicine  7 days’ supply 
Trauma benefit Covers certain day-to-day benefits that form part of the recovery following specific traumatic events, such as near drowning, poisoning, severe allergic reaction and external and internal head injuries. Appropriate treatment related to the event is covered as per authorisation
Medical rehabilitation, private nursing, Hospice and step-down facilities R58 000 per family
Health management programmes for conditions such as mental health, HIV/Aids and oncology Your doctor needs to register you on the appropriate health management programme 
Immune deficiency related to HIV
Anti-retroviral treatment
HIV related hospital admissions

No annual limit applies at preferred provider R48 300 per family at Evolve Network hospitals
Emergency medical transport in South Africa by
Netcare 911 
No annual limit applies 
International emergency medical transport by preferred provider R5 000 000 per beneficiary per 90-day journey. This benefit includes R15 500 for emergency optometry, R15 500 for emergency dentistry and R765 000 terrorism cover. A R2 180 co-payment applies per emergency out-patient claim
Specialised procedures/treatment
 Certain specialised procedures/treatment covered (when clinically appropriate) in - and out of hospital

Chronic Benefit

 

Chronic Benefit 

General rule applicable to the Chronic Benefit: Benefits are subject to registration on the Chronic Management

Programme and approval by the Scheme

Provider  

State facilities

Cover

26 conditions covered, according to Chronic Disease List in the Prescribed Minimum Benefits

Day-to-day Benefit

Day-to-day Benefit 
General rule applicable to the Day-to-day Benefit: Benefits are subject to Momentum HealthSaver, if available (see Momentum Complementary Product brochure for more details on HealthSaver) 
Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry Subject to HealthSaver if available 
Mental health (incl. psychiatry and psychology)  Subject to HealthSaver if available 
Dentistry – basic (such as extractions or fillings) Subject to HealthSaver if available 
Dentistry – specialised Subject to HealthSaver if available 
External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc)  Subject to HealthSaver if available 
General practitioners  2 virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. Consultations include scripting of medication where required. Medication will be subject to Momentum HealthSaver, if available
Sports injury benefit  2 physiotherapist or biokineticist visits per beneficiary per year for treatment related to sports injuries. Covered at 100% of the Momentum Medical Scheme Rate, up to a maximum of R1 120 per beneficiary per year. You need to get pre-authorisation
Specialists Subject to HealthSaver if available 
Optical and optometry (incl. contact lenses and refractive eye surgery  Subject to HealthSaver if available 
Pathology (such as blood sugar or cholesterol tests)  Subject to HealthSaver if available 
Radiology (such as X-rays)  Subject to HealthSaver if available 
MRI and CT scans, magnetic resonance  cholangiopancreatography (MRCP), whole body radioisotope and PET scans  Covered from Major Medical Benefit, subject to R3 200 co-payment per scan and pre-authorisation
Prescribed medication  Subject to HealthSaver if available 
Over-the-counter medication  Subject to HealthSaver if available 


Health Platform Benefit 

 

Health Platform Benefit 

General rule applicable to the Health Platform Benefit: Health Platform benefits are paid by the Scheme up to amaximum Rand amount per benefit. You do not need to pre-notify before using Health Platform Benefits, exceptfor preventative dental care, pap smears, general physical examinations and HIV tests. Where pre-notification isrequired, you can pre-notify quickly and easily on the Momentum App, via the web chat facility or by logging onto momentummedicalscheme.co.za. You may also send us a WhatsApp or call us on 0860 11 78 59.  

What is the benefit? 

Who is eligible? 

How often? 

Preventative care 

Baby immunisations  

Children up to age 6  

As required by the 

Department of Health 

Flu vaccines 

Children between 6 months and 5 years 

Beneficiaries 60 and older 

All high-risk beneficiaries  

Once a year 

Tetanus diphtheria injection 

All beneficiaries 

As needed 

Pneumococcal vaccine 

Beneficiaries 60 and older 

High-risk beneficiaries 

Once a year 

Early detection tests 

Dental consultation (incl. sterile tray and gloves) 

All beneficiaries 

Once a year 

Pap smear consultation (nurse, GP or gynaecologist) 

Women 15 and older 

Based on type of pap smear (see below) 

Pap smear (pathologist) 

Standard or LBC (Liquid based cytology) Or HPV PCR screening test (If result indicates high risk, then a follow-up LBC is also covered) 

 

Women 15 and older 

Women 21 to 65 

 

Once a year 

Once every 3 years 

 

Mammogram 

Women 38 and older 

Once every 2 years 

DEXA bone density scan (radiologist, GP or  specialist) 

Beneficiaries 50 and older 

Once every 3 years 

General physical examination (GP consultation) 

Beneficiaries 21 to 29 

Once every 5 years 

Beneficiaries 30 to 59 

Once every 3 years 

Beneficiaries 60 to 69 

Once every 2 years 

Beneficiaries 70 and older 

Once a year 

Prostate specific antigen (pathologist) 

Men 40 to 49 

Once every 5 years 

Men 50 to 59 

Once every 3 years 

Men 60 to 69 

Once every 2 years 

Men 70 and older 

Once a year 

Health assessment: Blood pressure test, cholesterol and blood sugar tests (finger prick tests), height, weight and waist circumference measurements 

All principal members and  adult beneficiaries 

Once a year  

Cholesterol test (pathologist): Only covered if health assessment results indicate total cholesterol of 6 mmol/L and above 

Principal members and adult beneficiaries 

Once a year 

Blood sugar (glucose) test (pathologist): Only covered if health assessment results indicate blood sugar levels of 11 mmol/L and above 

Principal members and     adult beneficiaries 

Once a year 

Glaucoma test 

Beneficiaries 40 to 49 

Once every 2 years 

Beneficiaries 50 and older 

Once a year 

HIV test (pathologist) 

Beneficiaries 15 and older 

Once every 5 years 

Maternity programme (subject to registration on the Maternity programme between 8 and 20 weeks of pregnancy) 

Doula benefit

Women registered on the programme 

2 visits per pregnancy 

Antenatal visits (Midwives, GP or gynaecologist) 

12 visits 

Nurse home visits 

2 visits, the day after returning from hospital following childbirth and 2 weeks later 

Urine tests (dipstick) 

Included in antenatal visits 

Pathology tests 

Blood group, creatinine, full blood count, glucose strip, haemoglobin estimation and 

Rhesus factor 

1 test

Urinalysis

12 tests
Urine tests (microscopic exams, antibiotic susceptibility and culture)  As indicated 
Scans 2 pregnancy scans. We cover 3D and 4D growth scans up to the rate that we pay for 2D scans 

Paediatrician visits 

Babies up to 12 months registered on the programme 

2 visits in baby’s first year 

Health line 

24-hour emergency health advice 

All beneficiaries 

As needed 


Disclaimer +Momentum Medical Scheme members may choose to make use of additional products available from Momentum Group Limited and its subsidiaries as well as Momentum Multiply (herein collectively referred to as Momentum). Momentum is not a medical scheme and is a separate entity to Momentum Medical Scheme. Momentum products are not medical scheme benefits. You may be a member of Momentum Medical Scheme without taking any of the products offered by Momentum.

 


Procedures covered in a day hospital

Procedures covered in day hospitals only
AnorectalTreatment of haemorrhoids, fissure, fistula
Covered for complicated cases that cannot be treated as an out-patient or where the out-patient treatment options failed and treatment is required in a medical facility
BiopsiesSkin, subcutaneous tissue, soft tissue, muscle, bone, lymph, eye, mouth, throat, breast, cervix, vulva, prostate, penis, testes
BreastLumpectomy (fibroadenoma)
Ear, nose and throatTonsillectomy and/or adenoidectomy (children up to 12 years) 
Simple procedures for nosebleed (extensive cautery) 
Sinus procedures (ethmoidectomy, sinusotomy and lavage) 
Scopes (nasal endoscopy, laryngoscopy) 
Middle ear procedures (myringoplasty, stapedectomy, myringotomy and/or grommets)
Cochlear implant
EyeCorneal transplant
Cataract surgery 
Treatment of glaucomai 
Other eye procedures: removal of foreign body, conjunctival surgery (repair laceration, pterygium), glaucoma surgery, probing and repair of tear ducts, retinal surgery, eyelid surgery, strabismus repair
Ganglionectomy
GastrointestinalGastrointestinal scopes (oesophagoscopy, gastroscopy, colonoscopy, sigmoidoscopy, proctoscopy, anoscopy)
GynaecologicalCerclage of uterine cervix 
D&C (dilatation and curettage)
 Endometrial ablation
 Hysteroscopy
 Sterilisation 
Laparoscopic gynaecological procedures (aspiration ovarian cyst, salpingectomy, fulguration/ablation/lysis of lesions)
Incision and drainageAbscess and/or cyst: skin (deep, non-superficial lesions), subcutaneous tissue and pilonidal
OrthopaedicArthroscopy, arthrotomy (shoulder, elbow, knee, ankle, hand, wrist, foot, temporomandibular joint), arthrodesis (hand, wrist, foot) 
Minor joint procedures (intercarpal, carpometacarpal and metacarpophalangeal, interphalangeal joint arthroplasty) 
Tendon and/or ligament repair, muscle debridement, fascia procedures (tenotomy, tenodesis, tenolysis, repair/reconstruction, capsulotomy, capsulectomy, synovectomy, excision tendon sheath lesion, fasciotomy, fasciectomy). Subject to individual case review 
Repair bunion or toe deformity 
Treatment of simple closed fractures and/or dislocations, removal of pins and plates
Subject to individual case review
Removal of foreign bodySubcutaneous tissue, muscle, external auditory canal under general anaesthesia
Simple superficial lymphadenectomy
SkinDebridement, removal of lesions (dependent on size and diameter), simple repair of superficial wounds
UrologicalCystoscopy 
Removal of ureteral stones 
Male genital procedures (circumcision for medical reasons only and when authorised, vasectomy)



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