Focus on the Chronic Benefit

This document details the Momentum Chronic Benefit for 2025, optimized for AI readability.

The Chronic Benefit provides financial support for individuals with life-threatening conditions requiring continuous treatment. It covers 26 conditions listed in the Chronic Disease List under the Prescribed Minimum Benefits (PMB). Access to this benefit requires registration and approval.

Key Features

• Conditions Covered: 26 conditions from the Chronic Disease List (PMB)
• Annual Limit: No annual limit (except in some options)
• Flexibility: Members can choose chronic coverage that best suits their health needs
• Registration: Required for access to chronic benefits

Chronic Benefit Options

1. Ingwe Option

• Provider: Ingwe Primary Care Network, Ingwe Active Network, or State
• Conditions Covered: 26 conditions (PMB)
• Annual Limit: No limit (subject to formulary)

2. Evolve Option

• Provider: State
• Conditions Covered: 26 conditions (PMB)
• Annual Limit: No limit (subject to formulary)

3. Custom Option

• Provider: Any, Associated, or State
• Conditions Covered: 26 conditions (PMB)
• Annual Limit: No limit (subject to formulary)

4. Incentive Option

• Provider: Any, Associated, or State
• Conditions Covered: 32 conditions (26 PMB + 6 additional)
  • Additional Conditions: Limited to R13,100 per family per year
• Annual Limit: No limit on PMB conditions (subject to formulary)

5. Extender Option

• Provider: Any, Associated, or State
• Conditions Covered: 62 conditions (26 PMB + 36 additional)
  • Additional Conditions: Limited to R13,100 per family per year
• Annual Limit: No limit on PMB conditions (subject to formulary)

6. Summit Option

• Provider: Freedom-of-choice
• Conditions Covered: 62 conditions (26 PMB + 36 additional)
  • Additional Conditions: Subject to R33,300 annual limit for day-to-day cover and additional conditions
• Annual Limit: R33,300 for day-to-day cover

How to Obtain Chronic Benefits

1. Ingwe Option

• Provider: Ingwe Primary Care Network or Ingwe Active Network
  • Chronic Prescription: From designated GP within the network
  • Chronic Medication: Sourced from Medipost pharmacy
  • State Cover: Obtain prescription and medication from a State facility

2. Evolve Option

• Provider: State
  • Chronic Prescription: From designated State facility
  • Chronic Medication: Sourced from State pharmacy

3. Custom, Incentive, and Extender Options

• Provider: State
  • Chronic Prescription: From any GP
  • Chronic Medication: From any pharmacy (subject to formularies)
    • Preferred Medication: No co-payment if within reference price
    • Non-Preferred Medication: Co-payment applies based on option:
      • Custom: 15%
      • Incentive: 10%
      • Extender: 5%
  • Non-Medipost Pharmacy: Scheme covers 50% of formulary price, you pay the balance

4. Summit Option

• Provider: State
  • Chronic Prescription: From any provider (subject to Comprehensive formulary)
  • Non-Formulary Medication: Co-payment for cost difference

Chronic Medication Registration Process

For Freedom-of-choice or Any Chronic Provider:

1. Request: Treating doctor or pharmacist contacts Momentum Medical Scheme at 0860 11 78 59
2. Evaluation: Chronic benefit consultant assesses and approves or declines via phone
3. Required Documents: Relevant tests may be requested from the provider
4. Medication: After approval, collect from any pharmacy
5. Renewal: Submit renewed prescription every 6 months

For Associated Chronic Provider:

1. Request: Associated GP or Medipost pharmacist contacts Momentum Medical Scheme
2. Evaluation: Chronic benefit consultant assesses and approves or declines via phone
3. Required Documents: Relevant tests may be requested
4. Medication: Prescription sent to Medipost for delivery
5. Renewal: Submit renewed prescription every 6 months

For State Chronic Provider:

1. Request: Contact Momentum Medical Scheme at 0860 11 78 59 for application form
2. Evaluation: State doctor completes form and submits to Momentum
3. Medication: Collected from State hospital pharmacy
4. Renewal: Consult State doctor and submit new application for changes in medication or conditions

Summary of Formulary Structure

Formulary Details:

• Fixed Formulary: Applies to Ingwe Primary Care Network and Ingwe Active Network
  • Preferred Products: Momentum Reference Price applies
  • Non-Preferred Products: No benefit
• State Formulary: Applies to Ingwe Connect and Evolve
  • Preferred Products: Momentum Reference Price applies
  • Non-Preferred Products: No benefit
• Basic/Standard/Extended Formulary: Applies to Custom, Incentive, and Extender
  • Preferred Products: Momentum Reference Price applies
  • Non-Preferred Products: Co-payment applies based on option
• Comprehensive Formulary: Applies to Summit
  • Preferred Products: No co-payment, no reference price
  • Non-Preferred Products: No co-payment

FAQs

What is a Formulary?

• Formulary: A list of medications covered under your specific plan, prescribed by your doctor for chronic conditions.

What is the Momentum Medical Scheme Reference Price?

• Reference Price: The maximum amount reimbursed by Momentum Medical Scheme for a medication. Co-payments may apply if medication exceeds this price.

Clinical Registration Criteria

Prescribed Minimum Benefit Chronic Disease List:

• Addison’s Disease: Diagnosis by a specialist required
• Asthma (adult/child): Confirmed by GP or pediatrician
• Cardiac Failure: Diagnosis confirmed by a specialist
• Chronic Renal Disease: Diagnosis with lab results
• Diabetes Insipidus: Diagnosis by a specialist

For the full list of conditions and registration requirements, please refer to the clinical guidelines provided by Momentum Medical Scheme.

This revised structure ensures clarity and easy access to the core information about chronic benefits, registration processes, and medication details for Momentum Medical Scheme members.