Health4Me Member guide 2019 - Your Health and Actuarial Consulting Specialists
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Health4Me Member guide 2019
Index 2 Day-to-day Benefits 2 How does the benefit work? 3 GP 4 Specialist 4 Basic and emergency dentistry 5 Basic optometry 6 Chronic benefit 7 HIV benefit 7 Maternity benefit 8 Flu vaccination 8 Hello Doctor 8 Health assessment 9 EAP services 9 Multiply Starter 10 Major Medical Event Benefits 10 Accident cover 11 Hopital cash benefit 12 Funeral benefit
Day-to-day Benefits
How does the benefit work?
There are three day-to-day benefit options. Please check on your Health4Me membership card or
membership certificate to find out which benefit option you are on, and if your family members are covered.
These are the benefits that are covered on the three benefit options:
Benefit Bronze Silver Gold
GP visits
GP in room procedures
Hello Doctor
Specialist visits
Acute medication
Chronic medication
HIV benefit
Basic pathology
Basic radiology
Basic and emergency dentistry
Basic optometry
Maternity benefit
Flu vaccination
Health assessment
EAP services
Multiply Starter
2
GP
GP visits Unlimited GP visits at a Momentum CareCross Network GP per member per
annum (authorisation is required after the 10th visit)
No out of Network GP visits will be allowed
GP in room Minor medical procedures performed as part of a Momentum CareCross Network
procedures GP consult in rooms
Acute medication Unlimited when provided in accordance with the Momentum CareCross Network
prescribed acute medication formulary
Basic pathology Unlimited when linked to a Momentum CareCross Network GP visit and referred
by a Momentum CareCross Network GP, according to the applicable Momentum
Health4Me pathology list
Basic radiology Unlimited cover for black and white x-rays, when linked to a Momentum CareCross
Network GP visit and referred by a Momentum CareCross Network GP, according
to the applicable Momentum Health4Me radiology list
You may visit any doctor on our GP Network for GP visits and acute medication. Acute medication is
medicine like antibiotics that you need to take for a few days only. Your GP can prescribe medication for
you from a list of approved medicines called a formulary. Your GP will either dispense the medicine to you
after your consultation, or give you a prescription that you can take to a pharmacy to get your medicine.
You can go to any pharmacy, but we suggest you go to a Dis-Chem, Clicks, MediRite or Pick n Pay
pharmacy, as other pharmacies might charge an extra fee, which you will have to pay.
Your Network GP may also send you for basic blood tests and black-and-white x-rays. We will pay the
account if the doctor is on the GP network, and if the blood tests or x-rays you have done are on the
approved list that we cover.
3Day-to-day Benefits
Specialist
A maximum of 2 visits per member/family per annum
A maximum of R1 000 per visit and up to R2 000 per member/family per annum
Members may consult any specialist, subject to a Momentum CareCross Network GP referral and pre-
authorisation
Members need to pay any shortfalls
Waiting periods may apply
If you need to see a specialist, you must first visit your Network GP, who will give you a referral letter. You
will need to call us on 0860 10 29 03, to get authorisation. You have cover for two specialist visits per year.
The maximum amount we will pay per visit is R1 000, with a maximum for the year of R2 000 for you and
your family, if they are also covered.
Example: Let’s say the specialist charges you R1 200 for a visit. The specialist will send the account for
R1 200 to us for payment. We will pay the specialist R1 000, and your benefit left for the year will reduce
from R2 000 to R1 000. You will have to pay the additional R200 for the visit from our own pocket.
Please note that this benefit is only available if you are on the Gold option.
Basic and emergency dentistry
Covered at any dentist on the Momentum CareCross Dental Network
Basic dentistry such as fillings, extractions, infection control, cleaning and polishing of teeth
Specialised dentistry such as bridges, crowns, surgical extractions, implants, root canals, gold fillings,
dentures and braces are not covered
Provided in accordance with the Momentum CareCross Dental Network protocols and approved
Momentum Health4Me dentistry list
Waiting periods may apply
You may visit any dentist on the dental Network. You have benefits for basic dentistry, such as fillings,
extractions, infection control and cleaning and polishing of teeth. The dentist will send the account to us
for payment. Specialised dentistry, such as bridges, crowns, surgical extractions, implants, root canals, gold
fillings, dentures and braces, is not covered. If a specific dental procedure is not covered, the dentist will let
you know and you will need to pay for it from your own pocket.
Please note that this benefit is only available if you are on the Silver and Gold options.
4Basic optometry
Covered at any optometrist on the Momentum CareCross Optical Network
Benefit available every 2 years
1 Eye test and 1 pair of clear standard single vision lenses, or 1 pair of bi-focal lenses, with a standard
frame
Sunglasses, tinted lenses, hard coating and contact lenses are not covered
Provided in accordance with the Momentum CareCross Optical Network protocols and approved
Momentum Health4Me optometry list
Waiting periods may apply
You may visit any optometrist on the optical Network. You will have cover for one eye test and one pair
of clear standard single vision lenses, or one pair of bi-focal lenses, with a standard frame, every 2 years.
The optometrist will test your eyes and tell you if you need glasses. If your eye test shows a reading of
0.75 or more, the optometrist will show you which frames you can choose from. The optometrist will send
the account to us for payment. If your eye test shows that you do not need glasses (a reading of less than
0.75), the optometrist will need to send us a motivation letter, to let us know why the glasses are needed. If
the optometrist does not send us the motivation letter, then we will pay for the visit only. We do not cover
sunglasses, tinted lenses, hard coating or contact lenses.
Please note that this benefit is only available if you are on the Silver and Gold options.
Important information
Please remember to always make use of a network GP, dentist and optometrist. To find out which network
providers are near you, simply ask your Human Resources department to check for you, call us on
0860 10 29 03 or visit our website at momentum.co.za. When you visit a network GP, dentist or optometrist,
please ask him/her to check your benefits to make sure that you are covered for the treatment that you need.
You will find the name of your benefit option on your membership card included in your welcome pack. Always
make sure that you have your membership card with you when you need to access any of your benefits. Please
store your card in a safe place, and don’t give it to anyone else to use.
5Day-to-day Benefits
Chronic benefit
Unlimited when provided in accordance with the Momentum CareCross Network prescribed chronic
medication formulary
26 Chronic conditions are covered:
Addison’s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Dysrhythmias, Cardiac
Failure, Cardiomyopathy, Chronic Obstructive Pulmonary Disease, Chronic Renal Disease, Coronary Artery
Disease, Crohn’s Disease, Diabetes Insipidus, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, Epilepsy,
Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson’s
Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus and Ulcerative Colitis
Waiting periods may apply
Chronic medication is medicine that you need to take daily on an ongoing basis. If you have one of the
twenty six chronic conditions listed above, you will have access to the chronic medication benefit. If you are
already receiving medication from a state facility for your condition on a monthly basis, we suggest that you
continue to get your treatment from state. This means that you would not need to re-register on the state
chronic medication benefit programme, if you ever leave your employer.
QQ How do I register for the chronic medication benefit?
AA You will need to visit a Network GP. If your GP diagnoses one of the twenty six chronic conditions,
they will need to call us on 0860 10 29 03 to register you for the chronic medication benefit.
They can do this by completing the chronic medication benefit application form, and email it to
health4mechronic@momentum.co.za. We will review the request from your GP and tell your GP
if we need more information, such as blood test results, before we can confirm your benefit. If we
approve the benefit, your GP will give you a prescription for your chronic medication, according to an
approved list of medicines.
QQ Where can I get my chronic medication from?
AA You need to fax or email your prescription to Medipost Pharmacy, and then contact them to let them
know where they must deliver your medication every month. You can fax your prescription to 0866
82 33 17 or email it to mhealth@medipost.co.za. You can call Medipost Pharmacy on 012 426 4000.
We can only pay for your chronic medication if we have approved it and if your GP has prescribed it
from the approved list of medicines. You will need to get a new script from your Network GP every
six months, and send it to Medipost Pharmacy.
Please note that this benefit is only available if you are on the Gold option.
6HIV benefit
Antiretroviral medication provided in accordance with the Momentum CareCross Network prescribed HIV
medication formulary
Post-exposure prophylaxis (PEP) medication provided in accordance with the Momentum CareCross Network
prescribed HIV medication formulary, to prevent HIV infection in the event of accidental exposure to blood or
fluids from an infected person, or by any other means
Pathology related to condition monitoring according to the applicable Momentum Health4Me pathology list
Waiting periods may apply
You may go for one HIV ELISA screening blood test per year at a Network GP. If your screening blood test
result is positive for HIV, your GP will need to contact us to register you for the HIV medication benefit. The
HIV benefit also includes post-exposure prophylaxis treatment, to prevent HIV infection, in the event that
you are accidentally exposed to blood or fluids from an infected person, or by any other means.
QQ How do I register for the HIV medication benefit?
AA Your GP will need to call us on 0860 55 56 09 to register you for the HIV medication benefit.
They can do this by completing the HIV medication benefit application form, and fax it to
0860 77 77 56 or email it to health4mehiv@momentum.co.za. We will review the request from
your GP and we will tell your GP if we need more information, such as blood test results, before we
can confirm your benefit. If we approve the benefit, your GP will give you a prescription for your HIV
medication, according to an approved list of antiretroviral medicines.
QQ Where can I get my HIV medication from?
AA You need to fax or email your prescription to Medipost Pharmacy, and then contact them to let them
know where they must deliver your medication every month. You can fax your prescription to
0866 82 33 17 or email it to mhealth@medipost.co.za. You can call Medipost Pharmacy on
012 426 4000. We can only pay for your HIV medication if we have approved it and your GP has
prescribed it from the approved list of antiretroviral medicines. You will need to get a new script from
your network GP every six months, and send it to Medipost Pharmacy.
If you are already receiving antiretroviral medication from a state facility for your condition on a
monthly basis, we suggest that you continue to get your treatment from state. This means that you
would not need to re-register on the state HIV medication benefit programme, if you ever leave your
employer.
Please note that this benefit is only available if you are on the Gold option.
Maternity benefit
1 1st trimester growth scan per pregnancy
You will have cover for one maternity visit, which includes a 2D growth scan or ultrasound, per pregnancy.
You will need to visit a network GP who is certified to do growth scans, or be referred by a Network GP to
a gynaecologist. Please note that you can only be referred to a gynaecologist if you are on the Gold option.
If you do consult a gynaecologist, the scan will be paid from this benefit, but the visit will be paid from your
specialist visits benefit.
7Day-to-day Benefits
Flu vaccination
1 Flu vaccination per member per annum at any pharmacy clinic, preferably at a Dis-Chem, Clicks,
MediRite or Pick n Pay pharmacy clinic
Strengthening your immune system to protect yourself from the flu virus is important. You can go for one
flu vaccination per year. You can go to any pharmacy clinic to get your flu vaccination, but we suggest you
go to a Dis-Chem, Clicks, MediRite or Pick n Pay pharmacy clinic, as other pharmacies might charge an
extra fee, which you will have to pay.
Hello Doctor
Unlimited access to telephonic consultations and online/mobile health information via Hello Doctor
Hello Doctor offers you easy to understand health and medical services, letting you talk to a GP in any
language, any time you need to for free. If you need to speak to a GP, simply dial *120*1019# from your
cell phone and choose the relevant option to “ask a doctor to call you”. A registered GP will call you back
within an hour. You can also download the free Hello Doctor app from the app store on your cell phone, or
go to hellodoctor.co.za. The app and website will allow you the option of texting the GP instead of talking
over the phone. The Hello Doctor helpline is available during business hours if you experience any technical
problems. You can call the Hello Doctor helpline on 0872 30 00 02.
QQ How do I register for the Hello Doctor benefit?
AA You will need to contact us and provide us with your cell phone number, so that we can register you
for the Hello Doctor benefit, and send you your unique user name and password.
Health assessment
1 Health assessment per member per annum at a pharmacy clinic, preferably at a Dis-Chem, Clicks,
MediRite or Pick n Pay pharmacy clinic
Employer groups with more than 50 employees can have onsite screening done via Multiply
You may go for one health assessment per year, which includes a blood pressure test, cholesterol and blood
sugar finger prick tests, as well as height, weight and waist circumference screening. These tests will show
you the state of your health, and if you are at risk of developing a long-term condition. You can go to any
pharmacy clinic to do your health assessment, but we suggest you go to a Dis-Chem, Clicks, MediRite or
Pick n Pay pharmacy clinic, as other pharmacies might charge an extra fee, which you will have to pay.
8EAP services
The Employee Assistance Programme provides access to the following professional counselling and
wellness services:
—— Psycho social counselling
—— Trauma/critical incidence counselling
—— Legal assist, credit health and debt management services
The Employee Assistance Programme provides you with access to professional counselling and wellness
services. These services will help you to manage personal concerns that have an effect on your wellbeing,
productivity and performance at work. Through the Employee Assistance Programme, you have access
to confidential services, in a variety of languages, via a dedicated toll free contact centre, including the
following telephonic counselling services:
Psycho social counselling services
Professional councillors will help you to detect, identify and resolve personal and health problems, that may
negatively affect your wellbeing and your ability to perform at work.
Trauma and critical incidence counselling services
You have access to trauma support from experts and professionals 24 hours a day, 7 days a week.
Assistance will be provided if you have experienced physical and/or emotional trauma, such as rape,
hijacking, child abuse, death or suicide of a close family member, armed robbery or assault, domestic
violence, kidnapping or abduction.
Legal assist, credit health and debt management services
If you need legal, debt or financial wellness advice, you can get assistance from fully qualified and
experienced attorneys, financial consultants and debt rescue consultants.
Psycho social counselling, legal assist, credit health and debt management services are available from
Monday to Friday, from 8 in the morning until 4 in the afternoon.
You can access the Employee Assistance Programme by calling 0800 22 93 55 and selecting option 4 for
Momentum Health4Me.
Multiply Starter
Discounts provided as per the Multiply Starter benefit rewards partners and applicable discounts list
9Major Medical Event Benefits
Accident cover
Emergency transportation, stabilisation and treatment cost paid in case of an accident that requires
immediate medical treatment
Covered at a private institution for accidents that fit the qualifying criteria (including casualty benefit)
If the benefit limit is exceeded, and further treatment is required, the member will be transported to a
state facility for further care
An accident shall mean a medical emergency that is an external, unexpected event that is not traceable,
directly or indirectly, to a member’s state of mental or physical health prior to the event
Medical emergencies that do not fit the qualifying criteria will warrant transportation, stabilisation and
treatment at a state facility
Base option R200 000 per event limit
Standard option R1 000 000 per event limit
An accident can happen at any time and it is important that you know who to contact if you have access
to this benefit, and you are involved in an accident, and you need immediate medical treatment. To get
authorisation for emergency medical treatment call us on 0860 10 29 03. For emergency ambulance
transport, call 082 911. Based on your injuries, the ambulance staff will decide on the most suitable hospital
to take you to. If you have an authorisation number, the hospital will send the account to us for payment.
We will pay up to the per event limit for your emergency medical treatment. If you are hospitalised at a
private hospital, and the cost of your care is more than the per event limit, and you need further treatment,
you will be transported to a state hospital for further care.
You have cover for accidents that are external, unexpected events, such as burns, fractures or breaking
of limbs due to an accident. We do not cover emergencies that are due to natural causes, such as heart
attacks or strokes. You are not covered for injuries that happen while you are under the influence of alcohol,
or for claims for self-inflicted injuries, as well as injuries that you get while breaking the law or participating
in civil unrest.
Please check on your Health4Me membership certificate if you and your family (if included) have accident
cover.
10Hospital cash benefit
Daily benefit amount paid per day spent in hospital, paid from day 1, provided that hospitalisation is
longer than 48 hours
Maximum of R20 000 payable per member per annum
Maternity lump-sum benefit payable to a member if hospitalisation is due to child birth, irrespective of
the number of days the member has been hospitalised
Waiting periods may apply
Base option R500 daily benefit amount
Maximum of 40 days payable per member per annum
R10 000 maternity lump-sum benefit
Standard option R1 000 daily benefit amount
Maximum of 20 days payable per member per annum
R20 000 maternity lump-sum benefit
The hospital cash benefit pays you a daily benefit amount per day spent in hospital, provided that you are in
hospital for more than two days, if you have this benefit. This benefit helps you to pay for any unexpected
costs that you may have due to being hospitalised, such as transport for your family to visit you while you
are in hospital, or to supplement your income due to time taken off from work.
We do not cover claims for hospitalisation due to psychological or psychiatric diseases or disorders,
investigation of pain or pain-related conditions, or for hospitalisation due to procedures that a member
chose to have done, that are not medically necessary, such as cosmetic surgery, abortion, infertility
treatment, treatment of impotence or artificial insemination.
If you are hospitalised due to child birth, we will pay you a maternity lump-sum benefit per child birth,
irrespective of the number of days that you have been hospitalised. The maternity lump-sum benefit has a
twelve month waiting period applicable from your membership inception date.
Hospital cash benefit claims have to be submitted within four months of the claim event date (the 1st day
of hospitalisation). If you do not submit your claim within four months of the claim event, your claim will be
rejected.
Please check on your Health4Me membership certificate if you and your family (if included) have the
hospital cash benefit.
11Major Medical Event Benefits
Funeral benefit
Funeral benefit paid in the event of death
Base option Employee, spouse and children > 14: R10 000
Children 6 - 13 years: R5 000
Children 1 - 5 years: R2 500
Children < 1 year: R1 250
Stillborn babies (past 28 weeks gestation): R750
Waiting periods may apply (natural causes of death)
Standard option Employee, spouse and children > 14: R15 000
Children 6 - 13 years: R7 500
Children 1 - 5 years: R3 750
Children < 1 year: R1 875
Stillborn babies (past 28 weeks gestation): R1 125
Waiting periods may apply (natural causes of death)
The funeral benefit will help pay for the funeral expenses in the event that you, your spouse or one of your
children passes away, if you have this benefit.
If you pass away, the funeral benefit will be paid to your spouse or to the person responsible for making
your funeral arrangements. If your spouse or one of your children passes away, the funeral benefit will be
paid to you.
Funeral benefit claims have to be submitted within four months of the claim event date (the date of death).
If you do not submit your claim within four months of the claim event, your claim will be rejected.
Please check on your Health4Me membership certificate if you and your family (if included) have the
funeral benefit.
QQ How do I submit a hospital cash benefit or funeral benefit claim?
AA To submit a hospital cash benefit or funeral benefit claim, you can go to your Human Resources
department, who will get the hospital cash benefit or funeral benefit claim form either by
downloading it from our employer web portal, by calling us on 0860 10 29 03 or by emailing us at
health4me@momentum.co.za. Once you have completed the claim form and have the documents
we require as stated on the claim form, you can ask your Human Resources department to either
email the documents to us at health4me@momentum.co.za, or to fax the documents to us at
031 580 0500.
12Who do I speak to if I have a query or need more information about my cover?
If you need more information about your Health4Me benefits, you can call us on 0860 10 29 03 or speak to
your HR d epartment.
0860 10 29 03
031 580 0500
health4me@momentum.co.za
201 uMhlanga Ridge Boulevard Cornubia 4339
PO Box 2338 Durban 4000 South Africa
momentum.co.za
Version 2019
Health4Me is not a medical scheme product, and is not a substitute for medical scheme membership.
Momentum is a division of MMI Group Limited. MMI Group Limited, an authorised financial services provider (FSP 6406), is a wholly owned
subsidiary of MMI Holdings Limited.You can also read
