Focus on the Chronic Benefit 2025

Chronic Benefit structure

The Chronic Benefit covers certain life-threatening conditions that need ongoing treatment and includes cover for the 26 Chronic Disease List conditions, which form part of the Prescribed Minimum Benefits. Chronic benefits are subject to registration and approval. 

Momentum Medical Scheme offers a unique Chronic Benefit structure that empowers members to choose the level of chronic cover appropriate to their family’s needs. The following table summarises the different levels of chronic cover and chronic providers across the six options.

How to obtain Chronic Benefits

How to register for chronic medication

Freedom-of-choice or Any chronic provider 

1.  Ask your treating doctor or pharmacist to contact us on 0860 11 78 59. 
2.  The chronic benefit consultant will either approve or decline the benefit telephonically. 
3.  We may need additional information from your provider, such as the ICD-10 code (diagnosis code) and applicable test results, in order to complete the registration process for your condition or medicine. Refer to the list at the end of this document for clinical information that the treating doctor may need to send per diagnosis for your chronic registration. 
4.  Once the chronic registration has been approved, you may get your medication from any pharmacy. Please provide a copy of your prescription to your pharmacy. 
5. You will need to renew the prescription every six months with your pharmacy.

Associated chronic provider

1. Ask your treating Associated GP or Medipost pharmacist to contact us on 0860 11 78 59.
2.  The chronic benefit consultant will either approve or decline the benefit telephonically.
3.  We may need additional information from your provider, such as the ICD-10 code (diagnosis code) and applicable test results, in order to complete the registration process for your condition or medicine. Refer to the list at the end of this document for clinical information that the treating doctor may need to send per diagnosis for your chronic registration. 
4.  Once your chronic registration has been approved, you need to send your prescription to Medipost to arrange for your chronic medication to be delivered. You can contact Medipost on 012 426 4000, and email your prescription to [email protected].
5.  You will need to renew the prescription every six months. If there are no changes to the medication or diagnosis, the prescription can be sent directly to Medipost, there will be no need to send it to us.

State chronic provider

1. Contact us on 0860 11 78 59 to ask for a State chronic application form to be sent to you. 
2.  Once you receive the form, take it to a State hospital and ask the State doctor to complete it. The doctor may also contact us on 0860 11 78 59. 
3. The doctor will assess you and prescribe medication as per the State formulary. 
4.  You need to collect your medication from the State hospital pharmacy. 
5.  The completed form can be emailed or posted to us, together with any relevant information and supporting documents to help us in processing the application. 
6.  If you or your dependant/s develop a new chronic condition, or need a change in medicine, you need to consult with a State doctor again and submit a new State chronic application form to us at [email protected].

Ingwe and Ingwe Active Network provider

1. Ask your Network doctor to contact us on 0860 11 78 59. 
2. The chronic benefit consultant will either approve or decline the benefit telephonically.
3.  We may need additional information from your doctor, such as the ICD-10 code (diagnosis code) and applicable test results, in order to complete the registration process for your condition or medicine. Refer to the list at the end of this document for clinical information that the treating doctor may need to send per diagnosis for your chronic registration. 
4. Once your chronic registration has been approved, you need to send your prescription to Medipost to arrange for your chronic medication to be delivered. You can contact Medipost on 012 426 4000, and email your prescription to [email protected].
5. If your doctor completes the Ingwe Option chronic application form, it can be emailed to us to facilitate the chronic registration process. You also need to send your prescription to Medipost for them to dispense and deliver the medication. 
6.  You can send your renewal prescription for your next refill directly to Medipost. There is no need to send it to us.

Important notes 

•  You need to register on the chronic management programme and get approval for chronic medication to be paid from the Chronic Benefit. 
•  Please refer to the list of chronic conditions in your member brochure for more information on the chronic conditions covered on your specific option. 
•  You can view the list of medication applicable to your benefit option at https://secure.mediscor.co.za/adocs/SchemeFormularies/momentum01.html.
•  Our chronic management programmes ensure that you receive the most appropriate treatment and medication. 
•  When a chronic condition is managed effectively, it is likely to result in fewer acute and long-term medical complications or side effects. We use evidence-based treatment principles, called clinical protocols, to determine and manage benefits for specific conditions. 
•  Please refer to the attached list of clinical entry criteria that apply when registering for chronic benefits for the first time. Your treating doctor will need to provide us with this information. 
• Prescriptions are valid for six months and you need to submit a new prescription to your pharmacy once your prescription expires. If you are diagnosed with a new chronic condition, need a change in your current medication or additional medication, please ask your treating doctor or pharmacist to contact us on 0860 11 78 59 for authorisation. Once the new prescription has been authorised, please submit it to your pharmacy.

Summary of Momentum Medical Scheme’s formulary structure

Frequently asked questions

What is a formulary? 

A formulary is a list of medicines covered on your option, from which a doctor can prescribe the appropriate medication for your chronic condition.

What is the Momentum Medical Scheme Reference Price?

The Momentum Medical Scheme Reference Price is the maximum rand value that Momentum Medical Scheme will pay for a medicine. If a new generic medicine is introduced, or the price of existing medication changes, medication that we previously covered in full, may now attract a co-payment.

We review the Momentum Medical Scheme Reference Price every year against a variety of factors, including price changes, any new medicines introduced or discontinued during the year, medical information, generic influence and medicine patents that have expired, to mention a few. This is to make sure that the reference pricing structure is kept up to date with the latest developments in medicine. The reference pricing will also be adjusted when a generic equivalent is launched where there was previously no generic available for the original product - this may happen at any time during the year.

Other important notes

• You need to register on the chronic management programme and get approval for chronic medication to be paid from the Chronic Benefit. 
• You can view the list of medication applicable to your benefit option at https://secure.mediscor.co.za/adocs/SchemeFormularies/momentum01.html.
• When a chronic condition is managed effectively, it is likely to result in fewer acute and long-term medical complications or side effects. We use evidence-based treatment principles, called clinical protocols, to determine and manage benefits for specific conditions.

Chronic conditions covered per option

The following 26 Chronic Disease List conditions are covered on the Ingwe, Evolve, Custom, Incentive, Extender and Summit Options:

* These are examples of medication not covered

On the Incentive Option, an additional 6 conditions are covered, subject to a limit of R13 100 per family per year.

On the Extender Option, an additional 36 conditions are covered, subject to a limit of R13 100 per family per year. 

On the Summit Option, the additional 36 conditions covered accumulate to the overall day-to-day limit of R33 300 per beneficiary per year.

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