Focus on the organ transplant programme

Below is information about the organ transplant programme

The following information outlines the details regarding the organ transplant program. For members who are in need of organ transplants, the Momentum Medical Scheme provides a specialized transplant program that includes a dedicated wellness coach. This coach collaborates closely with you and a team of specialized clinical staff to ensure that you receive the highest quality of care that is also cost-effective. Coverage is available, subject to pre-authorization, for a variety of services including pre-transplant evaluations, transplant surgeries, post-operative care, benefits following organ transplants, rehabilitation, as well as any necessary medications and medical tests.

How to Register for the Organ Transplant Benefit Once a decision has been made to proceed with an organ transplant, the transplant coordinator at the transplant unit is responsible for sending an email to register for the Organ Transplant Benefit. This email should include all necessary supporting documentation and must be directed to our Disease Risk Management Department at [e-mail]. The request needs to encompass several key elements, including:

• A comprehensive treatment plan along with a detailed quotation from the transplant unit or specialist.
• A motivational letter from your treating physician that includes the relevant diagnostic ICD-10 codes.
• A psychosocial assessment conducted by a psychiatrist and/or psychologist.
• Copies of all supporting tests and results that are pertinent to the diagnosis and the transplantation request.
• A breakdown of the hospitalization costs associated with each event.
• A detailed costing of immunosuppressive therapy on an annual basis.
• A cost estimate for the surgical procedure per event.

Live Organ Donor Request It is important to note that the donor search is not covered by the scheme. However, once a compatible match has been identified and approved, the tests related to the donor will be covered. To initiate a live organ donor request, the following documentation must be submitted alongside the previously mentioned materials:

• A copy of the blood group information for both the donor and recipient.
• A copy of the crossmatch results.
• A letter from the attending physician confirming that the donor is medically fit.

The scheme may also request additional information, such as the success rates of transplants. If all the necessary criteria are satisfied according to the scheme's benefits and clinical policies, you will be registered for the organ transplantation benefits under the Organ Transplant Programme. In cases where the criteria are not met, your information will be reviewed by the Clinical Governance Organ Transplant panel for a final decision. After a decision is reached, both you and your physician will be informed. Once the date for the transplant has been confirmed, you and your doctor must request authorization to proceed with the transplant by calling us at 0860 11 78 59. It is essential to provide the reference number that is included in the acceptance letter for the transplant.

Immunosuppressive Therapy Benefits Following your transplant, it is crucial to register for immunosuppressive therapy benefits. Your doctor can initiate this process by contacting our Chronic department at 0860 11 78 59, sending an email with a chronic script and ICD-10 codes to [e-mail], or faxing the information to 031 580 0471. Immunosuppressive therapy for Prescribed Minimum Benefit transplants is covered across all options, though this is subject to registration and approval at your Designated Services Provider.

How to Renew the Organ Transplant AuthorizationIf you are still awaiting a transplant after your initial registration, it is necessary to send a new cost estimate to the specialized coach in the Disease Risk Management department to confirm the previous approval when a suitable donor is located. If you have already undergone a transplant and your chronic medication authorization for immunosuppressants has expired, a new script must be submitted via email to [e-mail] or faxed to 031 580 0471 for renewal. Should there be any changes to your chronic medication, an updated script must also be sent to [e-mail] or faxed to 031 580 0471 to request authorization for the changes.

Important Notes It is essential to be aware of the following points regarding coverage: If you have opted for Ingwe Connect Network hospitals, your benefits will be limited to Prescribed Minimum Benefits at Connect Network hospitals. For those on the Ingwe Network or Any hospital option, benefits will also be limited to Prescribed Minimum Benefits at State facilities. If you are enrolled in the Evolve Option, your organ transplant benefits, including immunosuppressive therapy, are subject to Prescribed Minimum Benefits at State facilities. Additionally, if you are part of the Custom, Incentive, or Extender Option and you have selected Associated hospitals as your in-hospital provider, it is crucial to utilize an Associated hospital. Failure to do so will result in a 30% co-payment on the hospital bill. You can find the list of Associated hospitals in your member brochure or on our website at momentummedicalscheme.co.za. Alternatively, you can reach out to us through the web chat feature on momentummedicalscheme.co.za, email us at [e-mail], send a WhatsApp message, or call us at 0860 11 78 59 to verify which hospitals are included in the list. If you have selected Associated as your chronic provider, it is mandatory to obtain your chronic medication from Medipost, adhering to an entry-level Core formulary. If you acquire your chronic medication from outside the formulary, a co-payment will be applied. Furthermore, if you choose State as your chronic provider, you must utilize State facilities for post-organ transplant benefits and to procure your chronic medication, including immunosuppressive therapy. Lastly, immunosuppressive therapy for non-Prescribed Minimum Benefit transplants is covered under the Extender and Summit Options, contingent upon registration and approval.

Donor Benefits Donor benefits are available and are covered as follows: For those on the Custom Option, the coverage includes R24,900 for live donor costs (which encompasses transportation) and R50,400 for cadaver costs. For members on the Incentive, Extender, and Summit Options, the coverage is R27,500 for live donor costs (including transportation) and R56,000 for cadaver costs.

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

Contact UsFor any inquiries, you can reach us through the web chat facility on momentummedicalscheme.co.za, send an email to [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59.