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 benefits
| Step 1 | If you are diagnosed with cancer, consult with an oncologist or haematologist, if it was not an oncologist or haematologist who diagnosed you. The type of provider will depend on the type of cancer. Make sure you use the network provider applicable to your benefit option. |
| Step 2 | The doctor will decide on a treatment approach and communicate this to us for pre-authorisation. |
| Step 3 | The doctor will need to submit your histology, pathology and/or radiology reports to confirm your diagnosis to the Oncology Team via email at [email protected]. The doctor also needs to submit a treatment plan on a specific SAOC/ICON form, including the ICD-10 codes and any other relevant information for the treatment required. |
| Step 4 | The request will be evaluated by the Oncology Team. If required, we may contact you or your doctor for additional information. |
| Step 5 | Once we have all the information we need, your doctor will receive a response within 2 to 3 working days. |
What are the benefits?
Benefit option | Benefits |
| Ingwe Any hospital and Ingwe Network hospitals | Limited to Prescribed Minimum Benefits at State facilities |
| Ingwe Connect Network hospitals | Limited to Prescribed Minimum Benefits at Connect Network hospitals for approved in-patient care. For out-patient care, you need to make use of ICON oncologists. |
| Evolve | R200 000 per beneficiary per year, thereafter a 20% co-payment applies. Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medication. SAOC Tier 1/primary level of care benefits apply, subject to approval. |
| Custom | R300 000 per beneficiary per year, thereafter a 20% co-payment applies. Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medication. SAOC Tier 1/primary level of care benefits apply if you have chosen Associated or Any chronic provider, subject to approval. ICON Essential formulary/primary level of care benefits apply if you have chosen State chronic provider. |
| Incentive | R400 000 per beneficiary per year, thereafter a 20% co-payment applies. Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medication. SAOC Tier 1 to standard level of benefits apply if you have chosen Associated or Any chronic provider, subject to approval. ICON Essential formulary/primary level of care benefits apply if you have chosen State chronic provider. Cases which meet clinical criteria for exception management have access to certain specialised oncology medicines and treatment on Tier 3, up to a sub-limit of R200 000 within the oncology limit. |
| Extender | R500 000 per beneficiary per year, thereafter a 20% co-payment applies. Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medication. SAOC Tier 1 to standard level of benefits apply if you have chosen Associated or Any chronic provider, subject to approval. ICON Essential formulary/primary level of care benefits apply if you have chosen State chronic provider. Cases which meet clinical criteria for exception management have access to certain specialised oncology medicines and treatment on Tier 3, up to a sub-limit of R200 000 within the oncology limit. |
| Summit | No annual limit applies. Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medication. SAOC Tier 1 to 2 benefits apply, subject to approval. Cases which meet clinical criteria for exception management have access to certain specialised oncology medicines and treatment on Tier 3, up to a sub-limit of R200 000. |
Please note: The annual oncology limits apply per benefit year from 1 January to 31 December. If you join the Scheme during the year, and there is no waiting period applied on your membership, your benefit will be pro-rated for the number of months left in the year. The full annual limit for your chosen benefit option will be available from 1 January of the following year.
Which oncology provider and pharmacies may you use?
Your benefit option determines which oncology provider and pharmacy you may use | |
| Benefit option | Oncologist, haematologist and pharmacy |
| Ingwe Any hospital and Ingwe Network hospitals | State facilities |
| Ingwe Connect Network hospitals | ICON Network oncology providers – click here for the list Medipost Pharmacy for medicine If you obtain your oncology benefits from a non-network provider, you will need to pay 20% of the accounts for all oncology benefits, including pathology, radiology and medication |
| Evolve | List of Evolve Network oncologists – click here for the list Medipost Pharmacy for medicine If you obtain your oncology benefits from a non-network provider, you will need to pay 20% of the accounts for all oncology benefits, including pathology, radiology and medication |
| Custom, Incentive and Extender – State chronic provider | ICON Network oncology providers – click here for the list Medipost Pharmacy for medicine Treatment is subject to the ICON Essential Treatment Protocols If you obtain your oncology benefits from a non-network provider, you will need to pay 20% of the accounts for all oncology benefits, including pathology, radiology and medication |
| Custom, Incentive and Extender – Associated chronic provider | Any SAOC registered oncology provider Medipost pharmacy for medicine |
| Custom, Incentive and Extender – Any chronic provider | Any SAOC registered oncology provider Any pharmacy for medicine |
| Summit | Any SAOC registered oncology provider Any pharmacy for medicine |
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 Tiered Guidelines or ICON Essential formulary, 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
Scans that are not directly related to the cancer are not 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) 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 Tiered Guidelines or ICON Essential formulary or the Scheme Rules.
- Acute medication, eg antibiotics, antidepressants, anxiety or sleeping tablets, vitamins and homeopathic medicines. These may be paid from Day-to-day benefits or HealthSaver+ funds, if available.
- External breast prosthesis, special bras, stoma products and oxygen. These are covered from the Major Medical Benefit applicable limit based on your benefit option. Surgery to remove the affected area or organ is not paid from your oncology limit. It is covered from your Major Medical Benefit, which helps to preserve your oncology limit. The only exception is Robotic-Assisted Laparoscopic Prostatectomy (RALP), which is covered from the oncology limit when the required criteria are met.
- 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.
- The standard Custom Option co-payment that applies to hospital admissions is not covered from the oncology benefit.
- Dental benefits and dental complications related to chemotherapy and radiation are funded from Day-to-day benefits or HealthSaver funds, if available.
- Wigs are funded from Day-to-day benefits or HealthSaver funds, if available.
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. Oncology benefits still apply to non-Prescribed Minimum Benefit cancer treatment, except on the Ingwe Option, which covers Prescribed Minimum Benefits only.
If you exceed the oncology limits for the treatment of cancer, the Scheme will fund 80% of the benefit for the remainder of the year, which means you 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.
| Member contact centre | 0860 11 78 59 – WhatsApp or call |
| [email protected] | |
| Web | momentummedicalscheme.co.za |
Support centres for oncology patients
| Cancer Association of South Africa (CANSA) | Toll free: 0800 22 66 22 | Email: [email protected] |
| People Living With Cancer (PLWC) | Toll free: 0800 03 33 37 Tel: 021 565 0039 | Email: [email protected] |
| Reach for a dream | Tel: 011 880 1740 | Email: [email protected] Web: reachforadream.org.za |
| The Sunflower Fund | Toll free: 0800 12 10 82 | Web: sunflowerfund.org.za |
Glossary of terms
Term | Description |
| Momentum Medical Scheme Reference Pricing | Momentum Medical Scheme Reference Pricing is the maximum rand value that the Scheme will pay for a medicine. If you claim for a medicine that costs more than the reference pricing, you will need to pay the difference in cost. |
| Generic medication | A generic drug is a pharmaceutical drug that is equivalent to a brand-name product in dosage, strength, route of administration, quality, performance, and intended use, but does not carry the brand name. The generic drug has the same active pharmaceutical ingredient as the original, but may differ in characteristics such as manufacturing process, colour, taste and packaging. |
| ICD-10 code | This is a system of coding that notes various medical records including diseases, symptoms, abnormal findings and external causes of injury. It is your diagnosis code. |
| ICON | Independent Clinical Oncology Network |
| Oncologist | A doctor who specialises in the diagnosis and treatment of cancer. |
| Prescribed Minimum Benefits | Prescribed Minimum Benefits (PMBs) is a list of benefits for which all medical schemes in South Africa have to provide cover in terms of the Medical Schemes Act 131 of 1998 and the Regulations thereto. In order to access these benefits:
If you use non-designated service providers in cases of an emergency medical condition, it is deemed involuntary and co-payments are therefore waived. If your medical condition and treatment do not meet the above criteria to access these benefits, we will pay according to the benefits on your chosen benefit option. |
| SAOC | South African Oncology Consortium |