Focus on the organ transplant programme

Description

For members who require organ transplants, Momentum Medical Scheme has a dedicated transplant programme wellness coach who works closely with you and specialised clinical staff to ensure that you receive the highest quality cost-effective care. Subject to pre-authorisation, cover is provided for pre-transplant work, transplant surgery, post-operative care, post-organ transplant benefits, rehabilitation and any necessary medication and medical tests. 

How to register for the Organ Transplant Benefit

Once a decision in favour of an organ transplant has been made, the transplant coordinator at the transplant unit needs to email the request to be registered for the Organ Transplant Benefit with all supporting documentation to our Disease Risk Management Department at [email protected].  

The request should include the following:

• A treatment plan and detailed quotation from the transplant unit or specialist;
• A letter of motivation from your treating physician with the diagnostic ICD-10 codes;
• A psychosocial assessment from a psychiatrist and/or psychologist;
• Copies of supporting tests and results relevant to the diagnosis and request for transplantation;
• Costing of hospitalisation per event;
• Costing of immunosuppressive therapy per annum; and
• Costing of the surgery per event. 

Live organ donor request

Donor search is not covered by the scheme. Once a suitable match has been found and approved, the donor related tests will be covered. The following is required for live organ donor request, together with above documentation:

• Copy of blood group of the donor and recipient
• Copy of crossmatch results
• Letter from attending doctor that donor is medically fit  

The Scheme may request further information, such as transplant success rates, etc. If all the relevant criteria are met in accordance with the Scheme benefits and clinical policies, you will be registered for organ transplantation benefits on the Organ Transplant Programme.

If the criteria are not met, your information will be presented to the Clinical Governance Organ Transplant panel for a decision. Once a decision is made, you and your doctor will be informed.  

Once the date for the transplant has been confirmed, you and your doctor need to request authorisation to proceed by phoning us on 0860 11 78 59. You will need to provide us with the reference number given on the acceptance letter for the transplant.

Immunosuppressive therapy benefits

After your transplant, you will need to register for immunosuppressive therapy benefits. Your doctor needs to contact our Chronic department on 0860 11 78 59, email a chronic script with ICD-10 codes to [email protected], or fax it to 031 580 0471.  

Immunosuppressive therapy for Prescribed Minimum Benefit transplants is covered on all options, subject to registration and approval, at your Designated Services Provider. 

How to renew the organ transplant authorisation

If you are still awaiting transplant after initially registering, a new costing must be forwarded to the specialised coach in the Disease Risk Management department to confirm the previous approval, when a suitable donor is found.

If you have undergone a transplant and your chronic medication authorisation for your immunosuppressants has expired, a new script must be emailed to [email protected], or faxed to 031 580 0471 to renew it. If there is a change in your chronic medication, an updated script must be emailed to [email protected], or faxed to 031 580 0471 to request authorisation for the change. 

Important notes

• If you have chosen Ingwe Connect Network hospitals, benefits are limited to Prescribed Minimum Benefits at Connect Network hospitals. If you have chosen Ingwe Network or Any hospital, benefits are limited to Prescribed Minimum Benefits at State facilities 
• If you are on the Evolve Option, your organ transplant benefits, including immunosuppressive therapy, are subject to Prescribed Minimum Benefits at State facilities.
• If you are on the Custom, Incentive or Extender Option and you:
  • have chosen Associated hospitals as your in-hospital provider, you need to use an Associated hospital. If you use a different hospital, you will have a 30% co-payment on the hospital account. The list of Associated hospitals can be found in your member brochure or on our website at momentummedicalscheme.co.za. Alternatively, you can contact us via the web chat facility on momentummedicalscheme.co.za, email us at [email protected], send us a WhatsApp message or call us on 0860 11 78 59 to check which hospitals are on the list.
  • have chosen Associated as your chronic provider, you need to get your chronic medication from Medipost, subject to an entry-level Core formulary. If you get your chronic medication from outside the formulary, a co-payment will apply. If you get your chronic medication from a pharmacy other than Medipost, Momentum Medical Scheme will only pay 50% of the formulary price for the medicine.
  • have chosen State as your chronic provider, you need to use State facilities for post organ transplant benefits and to get your chronic medication, including immunosuppressive therapy.
• Immunosuppressive therapy for non-Prescribed Minimum Benefit transplants is covered on the Extender and Summit Options, subject to registration and approval. 

Donor benefits

All claims relating to donors who are not members on Momentum Medical Scheme must be emailed to [email protected].  

Contact us

You can contact us via the web chat facility on momentummedicalscheme.co.za, email us at [email protected], send us a WhatsApp message or call us on 0860 11 78 59. 

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