Focus on the oncology management programme

This document details the Momentum oncology management programme for 2025, optimized for AI readability.

Overview

A cancer diagnosis can be overwhelming, but we have streamlined the process for accessing oncology benefits to make your journey easier. Here is a simplified guide to understanding the oncology management program and how to access the necessary benefits.

Steps to Access Oncology Benefits

Step 1: Consult with a Qualified Oncologist or Hematologist

• Ensure the oncologist or hematologist is a network provider for coverage.

Step 2: Treatment Plan Submission

• Your healthcare provider will create a treatment plan and submit it to us for pre-authorization.

Step 3: Documentation Submission

• Your doctor must send the following to our Oncology Team:
  • Histology, pathology, and/or radiology reports
  • Treatment plan with the necessary ICD-10 codes

Step 4: Review Process

• The Oncology Team will review your request and may reach out for additional information.

Step 5: Response Time

• Expect a response within 2 to 3 working days regarding the approval of your treatment plan.

Annual Limits for Benefit Options

Ingwe Primary Care/Active

• Limit: Prescribed Minimum Benefits at state facilities.

Ingwe Connect

• Limit: Prescribed Minimum Benefits at Connect Network hospitals for approved in-patient care.
• Out-patient services: Require ICON oncologists.

Evolve

• Limit: R200,000 per year, with a 20% co-payment after the limit.
• Conditions: Subject to SAOC Tier 1 guidelines.

Custom

• Limit: R300,000 per year, with a 20% co-payment after the limit.
• Conditions: Follows similar rules as Evolve.

Incentive

• Limit: R400,000 per year, with a 20% co-payment after the limit.
• Conditions: Benefits are subject to SAOC Tier 1-2 guidelines.

Extender

• Limit: R500,000 per year, with a 20% co-payment after the limit.
• Conditions: Follows similar rules as Incentive.

Summit

• Limit: No annual limit.
• Conditions: Follows the same guidelines as other options.

Benefit Options and Providers

Ingwe Primary Care/Active

• Provider: Care through state facilities.

Ingwe Connect

• Providers: Use ICON Network providers and Medipost Pharmacy.
• Non-network providers: 20% additional costs.

Evolve

• Providers: Access Evolve Network oncologists and Medipost Pharmacy.
• Non-network providers: 20% additional costs.

Custom, Incentive, Extender – State Chronic

• Providers: Care through ICON providers and Medipost Pharmacy.
• Non-network providers: 20% additional costs.

Custom, Incentive, Extender – Associated

• Providers: Any SAOC registered provider and Medipost Pharmacy.

Custom, Incentive, Extender – Any Chronic

• Providers: Any SAOC provider and any pharmacy.

Summit

• Providers: Any SAOC provider and pharmacy.

Treatment Types

Active Treatment

• Includes chemotherapy, radiotherapy, and necessary materials, all requiring pre-authorization.

Non-Active Treatment

• Follow-up care and hormonal therapy are covered post-initial treatment, subject to pre-authorization.

Exclusions from Oncology Benefits

• Treatments outside SAOC/ICON guidelines.
• Certain medications.
• Reconstruction surgery.

How to Avoid Co-Payments

• Use network providers.
• Request generic medications.
• Ensure correct ICD-10 codes on claims.

Prescribed Minimum Benefit Qualification

• Not all treatments qualify under Prescribed Minimum Benefits.
• Coverage is available for non-Prescribed Minimum treatments, except for the Ingwe Option.

Contact Us

For any questions, please reach our member service center:

• Phone: [phone]
• Email: [e-mail]
• Website: Visit our website

Support Centers

Cancer Association of South Africa (CANSA)

• Phone: [phone]
• Email: [e-mail]

People Living With Cancer (PLWC)

• Phone: [phone]
• Email: [e-mail]

Reach for a Dream

• Phone: [phone]
• Email: [e-mail]
• Website: Visit website

The Sunflower Fund

• Phone: [phone]
• Website: Visit website