Focus on the organ transplant programme

Below is information about focus on the organ transplant programme

For individuals in need of organ transplants, the Momentum Medical Scheme offers a specialized transplant program that includes a wellness coach dedicated to guiding members through the process. This coach collaborates closely with a team of specialized clinical staff to ensure that you receive care that is not only of the highest quality but also cost-effective. Coverage for various aspects of the transplant process is available, contingent upon pre-authorization. This coverage encompasses essential services such as pre-transplant evaluations, the surgery itself, post-operative care, benefits following the organ transplant, rehabilitation services, and any necessary medications and medical tests that may be required throughout your treatment journey.

How to register for the Organ Transplant Benefit

Once it has been determined that an organ transplant is necessary, the transplant coordinator at the respective transplant unit must initiate the registration process for the Organ Transplant Benefit. This involves sending an email that includes a formal request, along with all supporting documentation, to our Disease Risk Management Department at [e-mail].

The registration request should include several critical pieces of information:

• A comprehensive treatment plan along with a detailed quotation from the transplant unit or the specialist involved in your care. This ensures that all parties have a clear understanding of the expected costs and procedures.

• A motivational letter from your treating physician, which should also include the relevant diagnostic ICD-10 codes. This letter serves to justify the medical necessity of the transplant.

• A psychosocial assessment conducted by a psychiatrist and/or psychologist, which evaluates the emotional and mental readiness of the patient for the transplant process.

• Copies of any supporting tests and results that are pertinent to the diagnosis and the request for transplantation. This documentation is crucial for validating the need for the procedure.

• A breakdown of the costs associated with hospitalization for each event. This helps in understanding the financial implications of the transplant.

• An annual costing estimate for immunosuppressive therapy, which is essential for preventing organ rejection post-transplant.

• A detailed cost estimate for the surgery itself, broken down by event.

Live organ donor request

Please note that the scheme does not cover the search for a donor. However, once a suitable donor has been identified and approved, the necessary tests related to the donor will be covered. To facilitate the live organ donor request, the following additional documentation is required, alongside the aforementioned documents:

• A copy of the blood group for both the donor and the recipient, which is crucial for compatibility.

• A copy of the crossmatch results, which further confirms the compatibility of the donor and recipient.

• A letter from the attending physician attesting to the donor's medical fitness, ensuring that the donor is in good health to undergo the procedure.

The Scheme may also request additional information, such as data on transplant success rates and other relevant metrics. If all the necessary criteria are satisfied according to the Scheme's benefits and clinical policies, you will be successfully registered for organ transplantation benefits under the Organ Transplant Programme.

In cases where the criteria are not met, your application will be presented to the Clinical Governance Organ Transplant panel for further review and decision-making. Once a determination has been made, both you and your doctor will be promptly informed of the outcome.

After the transplant date has been confirmed, it is essential for you and your doctor to request authorization to proceed with the procedure by calling our dedicated line at 0860 11 78 59. During this call, you will need to provide the reference number that was given to you in the acceptance letter for the transplant.

Immunosuppressive therapy benefits

Following your transplant, it is critical to register for immunosuppressive therapy benefits to ensure that you receive the necessary medications to prevent organ rejection. Your doctor must reach out to our Chronic department either by calling 0860 11 78 59, emailing a chronic prescription with the relevant ICD-10 codes to [e-mail], or faxing it to 031 580 0471.

Coverage for immunosuppressive therapy related to Prescribed Minimum Benefit transplants is available across all options, provided that registration and approval are obtained through your Designated Services Provider.

How to renew the organ transplant authorization

If you are still waiting for a transplant after having initially registered, it is necessary to submit a new cost estimate to the specialized coach in the Disease Risk Management department to confirm the previous approval once a suitable donor has been located.

If you have already undergone a transplant and your authorization for chronic medication related to immunosuppressants has expired, you will need to send a new prescription via email to [e-mail] or fax it to 031 580 0471 to renew the authorization. Should there be any changes to your chronic medication, an updated prescription must also be sent to the same email or fax number to request authorization for the new medication regimen.

Important notes

• If you are enrolled in the Ingwe or Evolve Option, please be aware that your organ transplant benefits, including immunosuppressive therapy, are subject to Prescribed Minimum Benefits and must be accessed through State facilities.

• For those on the Custom, Incentive, or Extender Option, it is important to note the following:

- If you have selected Associated hospitals as your in-hospital provider, you are required to utilize an Associated hospital for your care. Should you choose a different hospital, a co-payment of 30% will be applied to the hospital bill. A list of Associated hospitals is available in your member brochure or can be found on our website at momentummedicalscheme.co.za. You may also reach out to us via the web chat feature on our website, send an email to [e-mail], or contact us through WhatsApp or by calling 0860 11 78 59 to verify which hospitals are included in the list.

- If you have chosen Associated as your chronic provider, it is essential to obtain your chronic medication from Medipost, adhering to an entry-level Core formulary. If you procure your medication from sources outside of this formulary, a co-payment will be incurred. Additionally, if you obtain your chronic medication from a pharmacy other than Medipost, the Momentum Medical Scheme will only reimburse 50% of the formulary price for the medication.

- If you have selected State as your chronic provider, you must utilize State facilities for all post-organ transplant benefits and for obtaining your chronic medication, which includes immunosuppressive therapy.

• Immunosuppressive therapy for transplants that do not fall under the Prescribed Minimum Benefit category is covered under the Extender and Summit Options, contingent upon registration and approval.

Donor benefits

The coverage for donor benefits is structured as follows:

Custom Option - R47,900 is allocated for live donor expenses (which includes transportation costs), and R23,600 is designated for cadaver donor costs.

Incentive, Extender, and Summit Options - R53,000 is available for live donor expenses (including transportation), while R26,100 is allocated for cadaver donor costs.

All claims pertaining to donors who are not members of the Momentum Medical Scheme should be directed to [e-mail].

Contact us

For any inquiries or assistance, you can reach out to us using the web chat feature on momentummedicalscheme.co.za, send an email to [e-mail], communicate with us via WhatsApp, or call us directly at 0860 11 78 59.