Oncology Care Programme

We understand that a member that has just been diagnosed with cancer would have a lot to deal with
emotionally. With that in mind, we have compiled this information to provide you with a practical and
simplified approach to navigating the various steps to register for the Oncology Care Programme.

Should there be more technical questions, our team of highly experienced clinical coaches is available to
support you as required. Our coaches collaborate with doctors from the South African Oncology Consortium
(SAOC) and the Independent Clinical Oncology Network (ICON), to ensure that members have access to
treatment, support and education related to their condition.

How to access the oncology/cancer benefits

Members diagnosed with cancer need to consult with an Oncologist or Hematologist. This
Step 1
varies depending on the type of cancer
Step 2 The Oncologist/Hematologist will decide on a treatment approach and communicate this to us
The doctor will need to submit your histology, pathology and/or radiology reports to confirm
your diagnosis to the Oncology Team, via fax on 031 5800446, or via email to
Step 3
oncology@momentumhealth.co.za. The treatment plan needs to be submitted on a specific
SAOC / ICON form including the required ICD 10 codes (refer to glossary)
We will evaluate your request and, if required, we will contact your doctor for further
Step 4
discussion. We may request additional information from you
Step 5 You can expect a response from us within 2 to 3 working days

What are the benefit limits?

Benefit Option Overall Annual Limit

Ingwe Covered at State facilities for Prescribed Minimum Benefits only. This is
covered at State rates
Access Covered at State facilities for Prescribed Minimum Benefits only. This is
covered at State rates
Custom No annual limit. A 20% co-payment applies after treatment exceeds R300 000
per person per year
Incentive No annual limit. A 20% co-payment applies after treatment exceeds R400 000
per person per year
Extender No annual limit. A 20% co-payment applies after treatment exceeds R500 000
per person per year
Summit No overall annual limit
Your option determines which oncologist you may use

Option Oncologist
Ingwe State facilities
Access State facilities
Custom, Incentive and Momentum Associated Oncology Network
Extender Options A list of the Momentum Health Authorised oncologists is available from the
State chronic provider member call centre on 0860 11 78 59 or on www.momentumhealth.co.za
If you choose to obtain your oncology benefits from a non-authorised provider,
you will be liable to pay 20% of the accounts for all oncology benefits, including
pathology, radiology, medication and other related benefits and services.
Custom, Incentive and Any registered oncologist
Extender Options
Associated or Any
chronic provider
Summit Any registered oncologist

In-hospital specialist consultations are paid according to the in-hospital rate that applies to your option.
Out-of-hospital consultations are paid at 100% of the Momentum Health Rate.

What is covered?

Active management: Depending on the treatment plan, Chemotherapy, Radiotherapy, Brachytherapy and
Supportive treatment is covered. Treatment is approved in accordance with the SAOC and ICON
guidelines, Scheme Rules and benefit design. This is referred to as an active treatment plan. Materials
that are used in the administration of the active treatment, e.g. drips, needles and supporting treatment
are covered with the active treatment.

Non-active management: For members who still require follow-up (non-active) treatment after active
treatment is completed, the first 12 months treatment will be paid for by Momentum Health, in
accordance with Momentum Healths clinical protocols. Pre-authorisation is required for access to this
treatment.

Hormonal Therapy is used for several different types of cancers, e.g. breast and prostate cancer and is
covered according to SAOC and ICON guidelines.

External breast prosthesis, special bras, stoma products and oxygen are paid from the appliance limit
applicable to the members benefit option, subject to Scheme Rules.

Benefits for reconstruction are funded from the Major Medical Benefit. If the mastectomy was not done
while the member was on Momentum Health, we may request supporting documentation.

Benefits for Hospice and home-based nursing care are authorised from the relevant benefit where
clinically appropriate, in consultation with the treating oncologist. The level of care and associated cost is
also negotiated with private nursing agencies and Hospice facilities.

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 Consultations with the oncologist are covered at 100% of the Momentum Health Rate at the applicable
Designated Service Provider as per the benefit option.

Pathology tests (out-of-hospital) related to the condition during active treatment and after treatment for
follow-ups, as clinically appropriate are covered at 100% of the Momentum Health Rate if requested by
the treating doctor.

Radiology requested by the oncologist during active treatment and follow-up treatment thereafter will be
covered from the oncology benefit as per the treatment plan. This includes:
o Basic x-rays
o Scans required for diagnosis and staging
o Ultrasound isotope or nuclear bone scans.
If a scan is not directly related to the cancer, then it will not be covered from the oncology benefit.

Lymph drainage (physiotherapy) done by an accredited therapist may be paid from the oncology benefit if
the complication is the result of radiation and axillary clearance.

Clinical Coaches offer assistance to patients and their families who require follow-up care.

All benefits approved are covered at 100% of the Momentum Health Rate.

What is not covered?

Treatment that does not fall under the SAOC or ICON guidelines
Vitamins/homeopathic medicines and constipation medicine will be paid from day-to-day benefits, if
available
Any acute medication e.g. antibiotics, anti-depressants, sleeping tablets

How to avoid co-payments

Use a doctor within the network (as per your benefit option)
Ensure that treatment under the appropriate guidelines is used
Use generic medication
Treatment needs to be within the benefit limits on your option

What is a Prescribed Minimum Benefit in oncology?

Cancer must involve only the organ of origin

There should be no evidence of distant metastases (metastases means the spread of a cancer or
disease from one organ or part to another not directly connected with it)
No irreversible and irreparable damage to the organ of origin or any other organ

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Contact details

Member call centre 0860 11 78 59

Fax 031 5800 446
Email oncology@momentumhealth.co.za
Web www.momentumhealth.co.za

Support Centres for Cancer Patients

Cancer Association of South Africa (CANSA) Toll free number: 0800 22 66 22

Email: info@cansa.org.za
People Living With Cancer ( PLWC): Toll free number: 0800 033 337
Tel: 021 565 0039
Email: info@plwc.org.za
The Sunflower Fund Toll free number: 0800 12 10 82
Web: www.sunflowerfund.org.za
Reach for a dream Tel: 011 880 1740
Fax: 011 880 2108
Email: info@reachforadream.org.za
Web: www.reachforadream.org.za

Glossary of terms used in this document

Term Description
ICD10 Code This is a system of coding that notes various medical records including
diseases, symptoms, abnormal findings and external causes of injury.
It is your diagnosis code
Tariff codes These are the codes that are billed by the Service Provider for
services rendered
Prescribed Minimum Benefits Prescribed Minimum Benefits are defined benefits to ensure that all
medical scheme members have access to certain minimum health
services
DSP A designated service provider (DSP) is a healthcare provider (doctor,
pharmacist, hospital, etc.) that is a medical schemes first choice when
its members require diagnosis, treatment or care for a Prescribed
Minimum Benefit condition.
If a member voluntarily chooses not to use the DSP and uses a
different hospital, doctor or pharmacy, the medical scheme may
charge the member a co-payment
Oncologist A doctor who specialises in the diagnosis and treatment of cancer
SAOC South African Oncology Network
ICON Independent Clinical Oncology Network

If you have any queries, please feel free to call us on 0860 11 78 59.