Summary of Momentum Medical Scheme’s formulary structure
| Option | Formulary | Preferred products | Non-preferred products | Outliers |
| Ingwe Primary Care Network and Ingwe Active Network | Fixed formulary | Momentum Medical Scheme Reference Price applies | No benefit | No benefit |
| Ingwe Connect hospitals | State formulary | Momentum Medical Scheme Reference Price applies | No benefit | No benefit |
| Evolve | State formulary | Momentum Medical Scheme Reference Price applies | No benefit | No benefit |
Custom, Incentive and Extender – Any chronic provider | Custom: Basic formulary | Momentum Medical Scheme Reference Price applies | Momentum Medical Scheme Reference Price plus a percentage co-payment applies. This co-payment is 15% on the Custom Option, 10% on the Incentive Option and 5% on the Extender Option | |
| Incentive: Standard formulary | ||||
| Extender: Extended formulary | ||||
| Custom, Incentive and Extender – Associated chronic provider | Core formulary | Momentum Medical Scheme Reference Price applies. No penalty applies to products below the Momentum Medical Scheme Reference Price | Momentum Medical Scheme Reference Price plus a percentage co-payment applies. This co-payment is the difference in cost on the Custom Option, 20% on the Incentive Option and 15% on the Extender Option. If the non-preferred medication costs more than the Momentum Medical Scheme Reference Price, a co-payment for the difference in cost will be added to the percentage co-payment indicated above | Momentum Medical Scheme Reference Price plus 30% co-payment will apply |
| Custom, Incentive and Extender – State chronic provider | State formulary | Momentum Medical Scheme Reference Price applies | Momentum Medical Scheme Reference Price plus a percentage co-payment applies. This co-payment is 15% on the Custom Option, 10% on the Incentive Option and 5% on the Extender Option | Momentum Medical Scheme Reference Price plus 30% co-payment will apply |
| Summit | Comprehensive formulary | No co-payment Momentum Medical Scheme Reference Price does not apply | No co-payment. Momentum Medical Scheme Reference Price does not apply | A co-payment for the difference in the cost will apply |
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 you choose to use chronic medication that costs more than the reference pricing, you will need to pay the difference between the medicine you chose and the reference price. On occasion a product may fall below the reference price, but due to price changes, this price could change to fall above the reference price and thus attract a co-payment.
We review the Momentum Medical Scheme Reference Price every year against a variety of factors, including price changes, any medicine 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.
There are four categories in which a chronic product could fall:
- Preferred product with generic alternatives
- Preferred product without generic alternatives
- Non-preferred product with generic alternatives
- Non-preferred product without generic alternative.
Formulary products (preferred products): Any chronic provider
Generic reference pricing is applicable as Products A to C have the same active ingredients and strength – they are generic alternatives.
| Product | Active ingredient | Total cost | Generic Reference Price | Co-payment | Non-preferred co-payment (eg Incentive 10%) | Total co-payment |
| Product A | Ingredient A | R120 | R80 | R40 | N/A | R40 |
| Product B | Ingredient A | R80 | R80 | R0 | N/A | R0 |
| Product C | Ingredient A | R60 | R80 | R0 | N/A | R0 |
Formulary products (preferred products)
Generic reference pricing is not applicable as Product D does not have any generic alternatives.
| Product | Active ingredient | Total cost | Generic Reference Price co-payment | Non-preferred co-payment (eg Incentive 10%) | Total co-payment |
| Product D | Ingredient B | R100 | N/A | R0 | R0 |
Non-formulary products (non-preferred products)
Generic reference pricing is applicable as Products E to G have the same active ingredient and strength – they are generic alternatives. An additional fixed percentage of the total cost will also be applicable, based on your option, as follows:
- Custom Option: 15%
- Incentive Option: 10%
- Extender Option: 5%
| Product | Active ingredient | Total cost | Generic Reference Price | Co-payment | Non-preferred co-payment (eg Incentive 10%) | Total co-payment |
| Product E | Ingredient C | R140 | R100 | R40 | R14 | R54 |
| Product F | Ingredient C | R100 | R100 | R0 | R10 | R10 |
| Product G | Ingredient C | R90 | R100 | R0 | R9 | R9 |
Note: If you use a product on the formulary, a lower co-payment might apply.
Non-formulary products (non-preferred products)
Generic reference pricing is NOT applicable as Product H does not have any generic alternatives. An additional fixed percentage of the total cost will be applicable, based on your option as follows:
- Custom Option: 15%
- Incentive Option: 10%
- Extender Option: 5%
| Product | Active ingredient | Total cost | Generic Reference Price co-payment | Non-preferred co-payment (eg Incentive 10%) | Total co-payment |
| Product H | Ingredient D | R200 | N/A | R20 | R20 |
Formulary reference pricing on the Associated Chronic provider option
The formulary reference price on the Incentive Associated and Extender Associated Options has been enhanced to create more differentiation and allow members access to more products at a lower price:
- Custom Option: Formulary reference pricing
- Incentive Option: 20% co-payment
- Extender Option: 15% co-payment
Generic reference pricing is not applicable as Product D does not have any generic alternatives
| Product | Active ingredient | Total cost | Generic Reference Price co-payment | Non-preferred co-payment (eg Incentive 20%) | Non-preferred co-payment (eg Incentive 20%) |
| Product D | Ingredient B | R100 | N/A | R20 | R20 |
Generic reference pricing is applicable as Products H and J have the same active ingredient and strength – they are generic alternatives. An additional fixed percentage of the total cost will also be applicable.
| Product | Active ingredient | Total cost | Momentum Medical Scheme Reference Price | Generic Reference Price co-payment | Non-preferred co-payment (eg Incentive 20%) | Total co-payment |
| Product H | Ingredient D | R200 | R185 | R15 | R40 | R55 |
| Product J | Ingredient D | R300 | R285 | R15 | R60 | R75 |