Focus on the oncology management programme

We understand that a cancer diagnosis can be overwhelming, so we have tried to make registering on our oncology programme as simple as possible.  

How to access the oncology/cancer benefit

What are the benefit limits?

Which specialists and pharmacies may you use?

Active treatment

Active treatment is when a patient receives chemotherapy, radiotherapy (radiation) or brachytherapy depending on their diagnosis. Treatment is approved in accordance with the SAOC or ICON guidelines, Scheme Rules and benefit design.

• Chemotherapy - adjuvant chemotherapy is given to destroy any left-over cells after surgery to prevent possible reoccurrence. Palliative chemotherapy manages symptoms and slows disease progression. Momentum Medical Scheme Reference Pricing applies to both chemotherapy and adjuvant medication.
• Radiotherapy uses high-energy rays to destroy cancer cells. While radiotherapy also damages healthy cells, cancer cells cannot repair themselves, but healthy cells usually can. Palliative radiotherapy may also be given. 
• Materials used in the administration of the active treatment, eg drips, needles and supporting treatment are covered with the active treatment. 
• The treatment plan also includes consultations, infusion fees, pathology, radiology and medication required to treat the disease.  
• Consultations with the oncologist are covered at 100% of the Momentum Medical Scheme Rate at the applicable network provider as per your benefit option. 
• Pathology tests related to the condition are covered at 100% of the Momentum Medical Scheme Rate if requested by the treating network doctor, subject to being pre-authorised. 
• Radiology related to the condition is covered at 100% of the Momentum Medical Scheme Rate if requested by the treating network doctor, subject to being pre-authorised. This includes:
  • Basic x-rays and scans
  • Specialised radiology (CT, MRI and nuclear scans) - a co-payment may apply

If a scan is not directly related to the cancer, it will not be covered from the oncology benefit. 

Non-active treatment

Momentum Medical Scheme will pay for follow-up (non-active) treatment after the initial treatment is completed, subject to pre-authorisation.  

This includes:

• Hormonal therapy, which is used for several different types of cancers, eg breast and prostate cancer and is covered according to SAOC and ICON guidelines.
• Follow-up care, including consultations, pathology and radiology as listed above.
• Pain control for extensive spread of the disease.
• Lymph drainage (physiotherapy) done by an accredited therapist provided the complication is as a result of radiation and axillary clearance.
• Registered clinical coaches who assist patients and their families who require follow-up care. 

What is not covered from the oncology benefit?

• Treatment not provided for within the SAOC or ICON guidelines and formularies or the Scheme Rules.
• Acute medication, eg antibiotics, antidepressants, anxiety or sleeping tablets, vitamins and homeopathic medicines. These may be paid from available Day-to-day benefits.  
• External breast prosthesis, special bras, stoma products and oxygen. These are covered from the Major Medical Benefit applicable limit based on your benefit option.
• Reconstruction surgery does not form part of the oncology limit but is funded from the Major Medical Benefit. In the case of breast cancer, if the mastectomy was not done while the member was on Momentum Medical Scheme, we will request supporting documentation.
• Benefits for Hospice and home-based nursing care. This is paid from the relevant Major Medical Benefit, and will need to be pre-authorised in consultation with the treating oncologist. Limits apply depending on your benefit option. Please note that Hospice and private nursing are not covered on the Ingwe Option.
• Mental health benefits required as an impact of oncology need to be authorised. If authorised, treatment will be paid from the mental health benefit and limits applicable to your benefit option.  
• Treatment of chronic conditions which arise due to the impact of medication will be subject to your chronic benefit.
• Wigs are funded from available Day-to-day benefits. 

How to avoid co-payments

• Use doctors and pharmacies within your benefit option’s networks. With the help of your treating doctors, ensure that the treatment falls within the appropriate guidelines and formularies.  
• Ask your doctor to use generic medication. Your doctor will make the final decision on whether the generic medication is appropriate, but the funding of the medicine may be impacted.
• Where limits apply, treatment needs to be within the benefit limits on your benefit option.
• Ensure the correct ICD-10 codes related to the cancer are indicated on all claims submitted to us, including the pathology and radiology claims. Speak to your doctors to ensure they submit claims with the correct ICD-10 codes, per the treatment plans submitted, or as provided when authorised. 

When does oncology qualify as a Prescribed Minimum Benefit?

Not all cancer treatment is considered Prescribed Minimum Benefit treatment. This does not, however, mean there will be no cover if the cancer is a not a Prescribed Minimum Benefit, as oncology benefits still apply to non-Prescribed Minimum Benefit cancer treatment, except on the Ingwe Option, which cover Prescribed Minimum Benefits only.

Once oncology limits for the treatment of cancer are exceeded, the Scheme will fund 80% of the benefit for the remainder of the year, which means you as the member will be liable for 20% of the cost. 

Contact details

If you have any queries or need more information, you are welcome to contact us.

Support centres for oncology patients

Glossary of terms used in this document 

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