Every medical plan offered by Momentum includes a chronic benefit, which covers the cost of the diagnosis, treatment and care of chronic illnesses. Unfortunately, this is not an automatic benefit, and members need to register their chronic conditions with Momentum before the medical aid will cover these costs.
A number of members are needlessly paying for medication and other treatment (usually depleting their medical savings)when their medical plan should pay because they have not followed the registration requirements.
As the chronic benefit covers the diagnosis, treatment and care of the condition, there are various expenses associated with your chronic condition that are covered beyond the medication e.g. the cost of the GP consultation when you need to get a renewed script etc.
Chronic Options
Members have different options related to their chronic benefit depending on the plan that they are on. For the Custom, Incentive and Extender plans, members can choose to have either “Any”, “Associated”, or “State”, for the Evolve plan the only choice is “State” and on the Ingwe plan members need to follow the process associated with the “Associated” chronic option.
The process to follow for each option is as follows:
“Any” option (available on the Custom, Incentive and Extender plans)
- Ask your treating doctor or pharmacist to contact Momentum Medical Aid on 0860 11 78 59.
- The chronic benefit consultant will either approve or decline the benefit telephonically.
- Momentum may need additional information from your provider, such as the ICD-10 code (diagnosis code) and applicable test results, in order to complete the registration process for your condition or medicine. Refer to the list at the end of this document for clinical information that the treating doctor may need to send per diagnosis for your chronic registration.
- Once the chronic registration has been approved, you may get your medication from any pharmacy. Please provide a copy of your prescription to your pharmacy.
- You will need to renew the prescription every six months with your pharmacy.
“Associated” Option (available on the Custom, Incentive, Extender and “Ingwe plans)
- Ask your treating Associated GP or Medipost pharmacist to contact Momentum Medical Aid on 08601178 59.
- The chronic benefit consultant will either approve or decline the benefit telephonically.
- Momentum may need additional information from your provider, such as the ICD-10 code (diagnosis code) and applicable test results, in order to complete the registration process for your condition or medicine. Refer to the list at the end of this document for clinical information that the treating doctor may need to send per diagnosis for your chronic registration.
- Once your chronic registration has been approved, you need to send your prescription to Medipost to arrange for your chronic medication to be delivered. You can contact Medipost on 012 4264000, and email your prescription to mhealth@medipost.co.za.
- You will need to renew the prescription every six months. If there are no changes to the medication or diagnosis, the prescription can be sent directly to Medipost, there will be no need to send it to Momentum.
“State” Option
- Contact Momentum on 0860 11 78 59 to ask for a State chronic application form to be sent to you.
- Once you receive the form, take it to a State hospital and ask the State doctor to complete it. The doctor may also contact Momentum Medical Aid on 0860 11 78 59.
- The doctor will assess you and prescribe medication as per the State formulary.
- You need to collect your medication from the State hospital pharmacy.
- The completed form can be emailed or posted to Momentum Medical Aid, together with any relevant information and supporting documents to help in processing the application.
- If you or your dependant/s develop a new chronic condition, or need a change in medicine, you need to consult with a State doctor again and submit a new State chronic application form to us at member@momentum.co.za.
Formulary
The chronic option that you select will also determine the formulary (list of medication) that will be available to you e.g.
- On the “Any” chronic option you have the “Basic formulary”
- On the “Associated” option you have the “Core formulary”
- On the “State” option you have the “State” formulary and
- On the Ingwe plan you have the “Fixed formulary.
With the more expensive options, the formulary has a greater range of medication, and the Reference price is higher. All medication has a regulated Single Exit Price (SEP) which is the cost of the medication, including VAT but excluding any dispensing fee. The medical aid determines and pays the “Reference” price. If the Reference price is lower that the SEP, then the member may be liable for a co-payment.
Clinical criteria for registration on the chronic benefit
As noted above he requirements for registration will depend on the condition which are outlined in the table below:
| Prescribed Minimum Benefit Chronic Disease List conditions | Further information/tests required |
| Addison’s disease | Diagnosis by a specialist physician, paediatrician or endocrinologist |
| Asthma (adult) | Diagnosis confirmed by a GP or specialist |
| Asthma (child <7 years) | Diagnosis made or confirmed by a specialist paediatrician |
| Bipolar affective disorder | Psychiatrist prescription. Benzodiazepines excluded on Chronic Benefit |
| Bronchiectasis | Diagnosis confirmed by a specialist (entry criteria for pre-existing conditions will apply eg COPD) |
| Cardiac failure | Diagnosis confirmed by a specialist physician |
| Cardiac dysrhythmia | Diagnosis confirmed by a specialist physician |
| Cardiomyopathy | Diagnosis confirmed by a specialist physician |
| Chronic obstructive pulmonary disease | Diagnosis confirmed by a GP or specialist. Faxed or emailed copy of Lung function test performed to American Thoracic Society (or similar) criteria demonstrating FEV1/FVC<70% and FEV1 post bronchodilator <70% of predicted |
| Chronic renal disease | Diagnosis confirmed by a GP or specialist. Faxed copy of lab results required: serum creatinine clearance value <30ml/min or a Glomerular Filtration Rate estimate of <30ml/min |
| Coronary artery disease | Diagnosis confirmed by a specialist physician |
| Crohn’s disease | Diagnosis by a specialist physician, paediatrician, surgeon or gastroenterologist |
| Diabetes insipidus | Diagnosis by a specialist physician, paediatrician, neurologist, neurosurgeon or endocrinologist |
| Diabetes mellitus type 2 | Diagnosis confirmed by a GP or specialist physician.
Confirmatory lab results: • HbA1c >6% or • x2 random glucose >11mmol/l or • x2 fasting blood >7mmol/l or • x1 blood glucose >I5mmol/l or • GTT (fasting glucose of 7mmol/l or more and/or 2 hours post prandial glucose load of 11.1mmol/l or more) |
| Diabetes mellitus type 1 | Specialist initiation and confirmatory lab results as above |
| Epilepsy | Diagnosis confirmed by a GP, specialist physician, neurologist or neurosurgeon |
| Glaucoma | Diagnosis confirmed by an ophthalmologist |
| Haemophilia | Diagnosis confirmed by a specialist physician. Copy of lab results of Factor VIII or Factor IX levels of 5% or less |
| Hyperlipidaemia | Diagnosis confirmed by a GP or specialist physician. Faxed copy of lipogram results and documentation related to the risk assessment (Framingham Risk Score). Details of patient history: established vascular disease and details of any procedure performed eg angioplasty, stent, etc. Details of family history from prescribing doctor (to include details of cardiovascular events in member’s first degree relatives, including age of onset) |
| Hypertension | Diagnosis by a GP or specialist physician |
| Hypothyroidism | Diagnosis confirmed by a GP or specialist |
| Multiple sclerosis | Diagnosis confirmed by a specialist physician or neurologist. Initial application must be accompanied by a motivation which details disease progress, the EDSS score and an MRI report. |
Conclusion
Please ensure that you follow the above process to ensure that you receive the benefits that are due to you. Even if you have elected the “State” chronic options and do not collect your medication at a state facility, you can still be reimbursed the costs that the medical aid would have paid to the state facility.
