COUNTRY

Cover Area
Benefit Year
PRODUCT
Overall limit In Patient (IP)

Hospitalisation
(General medical and surgical wards)
Hospitalisation
(Executive/Private Ward))
Hospitalisation
(High Care and ICU)

Specialists and General Practitioners

Theatre Costs
Ward and Theatre medicines
Major Disease Benefit (MDB)
Oncology Subject to MDB

Organ Transplants *D Subject to MDB

Organ Transplants *D2 - donor
Chronic Dialysis- Subject to MDB
HIV Programme
Motor Vehicle Accident Subject to MDB
Step Down/Rehabilitation*P
Medicines to take home
Appliances
Specialised Radiology

Pathology
Radiology
Maxillofacial Surgery
Dental Surgery (subject to conditions)
Maternity
Neonatal, including neonatal ICU and related costs
Internal and external prosthesis
Physiotherapy *R
Psychiatric hospitalisations
Addictive conditions & disorders *L
Circumcision per beneficiary

Ambulance Services (In Country Only)

Air/Cross Borders Evacuation
Overall limit Out Patient (OP)

Consultations Limit
GP Consultations
Specialists Consultations
Antenatal Benefit*
Antenatal Consultations
Ultrasounds
Pathology

Procedures
Pathology
Radiology
HIV / AIDS Benefit *E
Anti-retroviral therapy
Pathology Tests

Basic Dentistry
Advanced Dentistry*P
Orthodontics not covered for age > 18
Physiotherapy *R
Auxiliary services *R

Psychology
Acute Medicines
OTC, Including supplements
Chronic Medicines *E
Chronic Benefits *E
Glucometer and Strips for Insulin Dependant Chronic Members
Optical Limit - per beneficiary every 12 months
Mono- / Bi- / Multifocal lenses
Every 12 months
Frames
Every 12 months
Eye Test
Every 12 months
Refractive surgery
Every 12 months

SPECIAL BENEFITS
Repatriation of mortal remains
24-hour health advice line
Wellness Program
 Antenatal Benefit*
Members have to register on a maternity program to qualify for these
benefits

*E = Enrolment Required
*P = Pre-Authorisation Required
*R = Referral by GP or Specialist required
*D = Donor not covered
*L = Lifetime benefit
*D2 = Donor only covered if donor is member of Momentum
Mozambique

Monthly Contributions
Description
Main member
Adult dependant
Child dependant

Description
Main member
Adult dependant
Child dependant
 MOZAMBIQUE
MOZAMBIQUE & RSA
July 2017 - June 2018
Platinum 1

No overall annual hospital limit

Benefits payable at 300% of
agreed tariff (Mozambique Price List)

Subject to overall IP Limit

No Benefits

15 days per beneficiary per annum

Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MZN 575 000 per family per annum
Subject to enrolment on oncology program
MZN 575 000 per family per annum
MZN 517 500 per family per annum
MZN 517 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
MZN 172 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
15 days per beneficiary per annum
MZN 178 250 per family per annum
Subject to overall IP Limit
7 days per beneficiary per annum
10 days per beneficiary per annum

Age < 15 subject to overall IP Limit

Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Subject to overall IP Limit
Subject to overall IP Limit
 MZN 632 500 per beneficiary per annum
16 visits per beneficiary per annum
Subject to Consultations limit
Subject to Consultations limit
Subject to overall OP Limit
4 Visits
2 Scans
1 Full blood count, 1 Elisa test,
ARV syrup for new born
MZN 99 188 per beneficiary per annum
Subject to Procedures Limit
Subject to Procedures Limit

Wellness program
MZN 72 450 per beneficiary per annum

MZN 39 100 per beneficiary per annum

MZN 27 600 per beneficiary per annum

MZN 27 600 per beneficiary per annum

Subject to pre-authorisation
MZN 97 750 per beneficiary per annum
MZN 2 070 per beneficiary per annum
MZN 239 200 per beneficiary per annum

Subject to Chronic Medicines Limit

MZN 83 030 per beneficiary per annum

MZN 42 550 per beneficiary per annum

MZN 37 605 per beneficiary per annum

MZN 2 875 per beneficiary per annum

Subject to Optical Limit

Platinum 1
Included
Included
Included (HIV / AIDS wellness and management program)
Platinum 1
SME
13,975
10,485
5,140

Corp
8,460
6,350
3,100
 MOZAMBIQUE
MOZAMBIQUE & RSA
July 2017 - June 2018
Platinum 2

No overall annual hospital limit

Benefits payable at 300% of
agreed tariff (Mozambique Price List)

Subject to overall IP Limit

No Benefits

15 days per beneficiary per annum

Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MZN 575 000 per family per annum
Subject to enrolment on oncology program
MZN 575 000 per family per annum
MZN 517 500 per family per annum
MZN 517 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
MZN 172 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
15 days per beneficiary per annum
MZN 178 250 per family per annum
Subject to overall IP Limit
7 days per beneficiary per annum
10 days per beneficiary per annum

Age < 15 subject to overall IP Limit

Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Subject to overall IP Limit
Subject to overall IP Limit
 MZN 382 950 per beneficiary per annum
13 visits per beneficiary per annum
Subject to Consultations limit
Subject to Consultations limit
Subject to overall OP Limit
4 Visits
2 Scans
1 Full blood count, 1 Elisa test,
ARV syrup for new born
MZN 59 513 per beneficiary per annum
Subject to Procedures Limit
Subject to Procedures Limit

Wellness program
MZN 40 250 per beneficiary per annum

MZN 22 425 per beneficiary per annum

MZN 17 250 per beneficiary per annum

MZN 17 250 per beneficiary per annum

Subject to pre-authorisation
MZN 57 500 per beneficiary per annum
MZN 2 070 per beneficiary per annum
MZN 149 500 per beneficiary per annum

Subject to Chronic Medicines Limit

MZN 52 325 per beneficiary per annum

MZN 25 875 per beneficiary per annum

MZN 23 000 per beneficiary per annum

MZN 2 300 per beneficiary per annum

Subject to Optical Limit

Platinum 2
Included
Included
Included (HIV / AIDS wellness and management program)
Platinum 2
SME
10,675
8,530
4,070

Corp
6,400
5,115
2,670
 MOZAMBIQUE
MOZAMBIQUE & RSA
July 2017 - June 2018
Platinum 3

No overall annual hospital limit

Benefits payable at 300% of
agreed tariff (Mozambique Price List)

Subject to overall IP Limit

No Benefits

10 days per beneficiary per annum

Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MZN 575 000 per family per annum
Subject to enrolment on oncology program
MZN 575 000 per family per annum
MZN 517 500 per family per annum
MZN 517 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
MZN 172 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
10 days per beneficiary per annum
MZN 178 250 per family per annum
Subject to overall IP Limit
7 days per beneficiary per annum
10 days per beneficiary per annum

Age < 15 subject to overall IP Limit

Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Subject to overall IP Limit
Subject to overall IP Limit
 MZN 152 950 per beneficiary per annum
11 visits per member per annum
Subject to Consultations limit
Subject to Consultations limit
Subject to overall OP Limit
4 Visits
2 Scans
1 Full blood count, 1 Elisa test,
ARV syrup for new born
MZN 19 838 per beneficiary per annum
Subject to Procedures Limit
Subject to Procedures Limit

Wellness program
MZN 14 548 per beneficiary per annum

No Benefit
MZN 5 750 per beneficiary per annum

No benefit
No benefit
MZN 23 575 per beneficiary per annum
MZN 2 070 per beneficiary per annum
MZN 50 600 per beneficiary per annum

Subject to Chronic Medicines Limit

MZN 17 710 per beneficiary per annum

MZN 8 625 per beneficiary per annum

MZN 7 475 per beneficiary per annum

MZN 1 610 per beneficiary per annum

Subject to Optical Limit

PLATINUM OPTION 3
Included
Included
Included (HIV / AIDS wellness and management program)
Platinum 3
SME
7,080
6,015
3,390

Corp
4,480
3,735
2,135
 MOZAMBIQUE
MOZAMBIQUE & RSA
July 2017 - June 2018
Bronze 1

MZN 4 508 000 per beneficiary per annum Benefits payable at 100% of
agreed tarrif (Mozambique price list)

MZN 1 150 000 per hospital episode

No Benefits

10 days per beneficiary per annum

Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MZN 575 000 per family per annum
Subject to enrolment on oncology program
MZN 575 000 per family per annum
MZN 517 500 per family per annum
MZN 517 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
MZN 172 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
10 days per beneficiary per annum
MZN 178 250 per family per annum
Subject to overall IP Limit
7 days per beneficiary per annum
10 days per beneficiary per annum

Age < 15 subject to overall IP Limit

Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Subject to overall IP Limit
Subject to overall IP Limit
 MZN 86 825 per beneficiary per annum
10 visits per beneficiary per annum
Subject to Consultations limit
Subject to Consultations limit
Subject to overall OP Limit
4 Visits
2 Scans
1 Full blood count, 1 Elisa test,
ARV syrup for new born
MZN 9 919 per beneficiary per annum
Subject to Procedures Limit
Subject to Procedures Limit

Wellness program
MZN 7 274 per beneficiary per annum

No Benefit
MZN 2 875 per beneficiary per annum

No Benefit
No Benefit
MZN 11 270 per beneficiary per annum
MZN 2 070 per beneficiary per annum
MZN 25 300 per beneficiary per annum

Subject to Chronic Medicines Limit

MZN 10 925 per beneficiary per annum

MZN 5 175 per beneficiary per annum

MZN 4 600 per beneficiary per annum

MZN 1 150 per beneficiary per annum

Subject to Optical Limit

Bronze 1
Included
Included
Included (HIV / AIDS wellness and management program)
Bronze 1
SME
5,140
4,280
2,420

Corp
4,265
3,530
2,025
 MOZAMBIQUE
MOZAMBIQUE
July 2017 - June 2018
Bronze 2

MZN 4 508 000 per beneficiary per annum

MZN 1 150 000 per hospital episode

No Benefits

10 days per beneficiary per annum

Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MZN 575 000 per family per annum
Subject to enrolment on oncology program
MZN 575 000 per family per annum
MZN 517 500 per family per annum
MZN 517 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
MZN 172 500 per family per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
Subject to overall IP Limit
10 days per beneficiary per annum
MZN 178 250 per family per annum
Subject to overall IP Limit
7 days per beneficiary per annum
10 days per beneficiary per annum

Age < 15 subject to overall IP Limit

Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Subject to overall IP Limit
Subject to overall IP Limit
 MZN 86 825 per beneficiary per annum
10 visits per beneficiary per annum
Subject to Consultations limit
Subject to Consultations limit
Subject to overall OP Limit
4 Visits
2 Scans
1 Full blood count, 1 Elisa test,
ARV syrup for new born
MZN 9 919 per beneficiary per annum
Subject to Procedures Limit
Subject to Procedures Limit

Wellness program
MZN 7 274 per beneficiary per annum

No Benefit
MZN 2 875 per beneficiary per annum

No Benefit
No Benefit
MZN 11 270 per beneficiary per annum
MZN 2 070 per beneficiary per annum
MZN 25 300 per beneficiary per annum

Subject to Chronic Medicines Limit

MZN 10 925 per beneficiary per annum

MZN 5 175 per beneficiary per annum

MZN 4 600 per beneficiary per annum

MZN 1 150 per beneficiary per annum

Subject to Optical Limit

Bronze 2
No Benefit
Included
Included (HIV / AIDS wellness and management program)
Bronze 2
SME
4,280
3,485
1,915

Corp
3,690
3,035
1,710
 COUNTRY MOZAMBIQUE
Cover Area MOZAMBIQUE & RSA
Benefit Year July 2017 - June 2018
PRODUCT Platinum 1
Overall limit In Patient (IP)
No overall annual hospital limit
Benefits payable at 300% of
agreed tariff (Mozambique Price List)
Hospitalisation
(General medical and surgical wards)
Subject to overall IP Limit
Hospitalisation
(Executive/Private Ward))
No Benefits
Hospitalisation
(High Care and ICU)
15 days per beneficiary per annum
Specialists and General Practitioners Subject to overall IP Limit
Theatre Costs Subject to overall IP Limit
Ward and Theatre medicines Subject to overall IP Limit
Major Disease Benefit (MDB) Subject to overall IP Limit
Oncology Subject to MDB
MZN 575 000 per family per annum
Subject to enrolment on oncology program
Organ Transplants *D Subject to MDB MZN 575 000 per family per annum
Organ Transplants *D2 - donor MZN 517 500 per family per annum
Chronic Dialysis- Subject to MDB MZN 517 500 per family per annum
HIV Programme Subject to overall IP Limit
Motor Vehicle Accident Subject to MDB Subject to overall IP Limit
Step Down/Rehabilitation*P MZN 172 500 per family per annum
Medicines to take home Subject to overall IP Limit
Appliances Subject to overall IP Limit
Specialised Radiology
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Pathology Subject to overall IP Limit
Radiology Subject to overall IP Limit
Maxillofacial Surgery Subject to overall IP Limit
Dental Surgery (subject to conditions) Subject to overall IP Limit
Maternity Subject to overall IP Limit
Neonatal, including neonatal ICU and related costs 15 days per beneficiary per annum
Internal and external prosthesis MZN 178 250 per family per annum
Physiotherapy *R Subject to overall IP Limit
Psychiatric hospitalisations 7 days per beneficiary per annum
Addictive conditions & disorders *L 10 days per beneficiary per annum
Circumcision per beneficiary
Age < 15 subject to overall IP Limit
Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Ambulance Services (In Country Only) Subject to overall IP Limit
Air/Cross Borders Evacuation Subject to overall IP Limit
Overall limit Out Patient (OP) MZN 632 500 per beneficiary per annum
Consultations Limit 16 visits per beneficiary per annum
GP Consultations Subject to Consultations limit
Specialists Consultations Subject to Consultations limit
Antenatal Benefit* Subject to overall OP Limit
Antenatal Consultations 4 Visits
Ultrasounds 2 Scans
Pathology
1 Full blood count, 1 Elisa test,
ARV syrup for new born
Procedures MZN 99 188 per beneficiary per annum
Pathology Subject to Procedures Limit
Radiology Subject to Procedures Limit
HIV / AIDS Benefit *E
Anti-retroviral therapy
Pathology Tests
Wellness program
Basic Dentistry MZN 72 450 per beneficiary per annum
Advanced Dentistry*P
Orthodontics not covered for age > 18
MZN 39 100 per beneficiary per annum
Physiotherapy *R MZN 27 600 per beneficiary per annum
Auxiliary services *R
MZN 27 600 per beneficiary per annum
Psychology Subject to pre-authorisation
Acute Medicines MZN 97 750 per beneficiary per annum
OTC, Including supplements MZN 2 070 per beneficiary per annum
Chronic Medicines *E MZN 239 200 per beneficiary per annum
Chronic Benefits *E
Glucometer and Strips for Insulin Dependant Chronic Members
Subject to Chronic Medicines Limit
Optical Limit - per beneficiary every 12 months MZN 83 030 per beneficiary per annum
Mono- / Bi- / Multifocal lenses
Every 12 months
MZN 42 550 per beneficiary per annum
Frames
Every 12 months
MZN 37 605 per beneficiary per annum
Eye Test
Every 12 months
MZN 2 875 per beneficiary per annum
Refractive surgery
Every 12 months
Subject to Optical Limit

SPECIAL BENEFITS Platinum 1

Repatriation of mortal remains Included
24-hour health advice line Included
Wellness Program Included (HIV / AIDS wellness and management program)

Antenatal Benefit*
Members have to register on a maternity program to qualify for these
benefits

*E = Enrolment Required
*P = Pre-Authorisation Required
*R = Referral by GP or Specialist required
*D = Donor not covered
*L = Lifetime benefit
*D2 = Donor only covered if donor is member of Momentum
Mozambique

Monthly Contributions Platinum 1

Description Corp
Main member 8,460
Adult dependant 6,350
Child dependant 3,100
Special dependant(Parents) 13,975
 COUNTRY MOZAMBIQUE
Cover Area MOZAMBIQUE & RSA
Benefit Year July 2017 - June 2018
PRODUCT Platinum 2
Overall limit In Patient (IP)
No overall annual hospital limit
Benefits payable at 300% of
agreed tariff (Mozambique Price List)
Hospitalisation
(General medical and surgical wards)
Subject to overall IP Limit
Hospitalisation
(Executive/Private Ward))
No Benefits
Hospitalisation
(High Care and ICU)
15 days per beneficiary per annum
Specialists and General Practitioners Subject to overall IP Limit
Theatre Costs Subject to overall IP Limit
Ward and Theatre medicines Subject to overall IP Limit
Major Disease Benefit (MDB) Subject to overall IP Limit
Oncology Subject to MDB
MZN 575 000 per family per annum
Subject to enrolment on oncology program
Organ Transplants *D Subject to MDB MZN 575 000 per family per annum
Organ Transplants *D2 - donor MZN 517 500 per family per annum
Chronic Dialysis- Subject to MDB MZN 517 500 per family per annum
HIV Programme Subject to overall IP Limit
Motor Vehicle Accident Subject to MDB Subject to overall IP Limit
Step Down/Rehabilitation*P MZN 172 500 per family per annum
Medicines to take home Subject to overall IP Limit
Appliances Subject to overall IP Limit
Specialised Radiology
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Pathology Subject to overall IP Limit
Radiology Subject to overall IP Limit
Maxillofacial Surgery Subject to overall IP Limit
Dental Surgery (subject to conditions) Subject to overall IP Limit
Maternity Subject to overall IP Limit
Neonatal, including neonatal ICU and related costs 15 days per beneficiary per annum
Internal and external prosthesis MZN 178 250 per family per annum
Physiotherapy *R Subject to overall IP Limit
Psychiatric hospitalisations 7 days per beneficiary per annum
Addictive conditions & disorders *L 10 days per beneficiary per annum
Circumcision per beneficiary
Age < 15 subject to overall IP Limit
Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Ambulance Services (In Country Only) Subject to overall IP Limit
Air/Cross Borders Evacuation Subject to overall IP Limit
Overall limit Out Patient (OP) MZN 382 950 per beneficiary per annum
Consultations Limit 13 visits per beneficiary per annum
GP Consultations Subject to Consultations limit
Specialists Consultations Subject to Consultations limit
Antenatal Benefit* Subject to overall OP Limit
Antenatal Consultations 4 Visits
Ultrasounds 2 Scans
Pathology
1 Full blood count, 1 Elisa test,
ARV syrup for new born
Procedures MZN 59 513 per beneficiary per annum
Pathology Subject to Procedures Limit
Radiology Subject to Procedures Limit
HIV / AIDS Benefit *E
Anti-retroviral therapy
Pathology Tests
Wellness program
Basic Dentistry MZN 40 250 per beneficiary per annum
Advanced Dentistry*P
Orthodontics not covered for age > 18
MZN 22 425 per beneficiary per annum
Physiotherapy *R MZN 17 250 per beneficiary per annum
Auxiliary services *R
MZN 17 250 per beneficiary per annum
Psychology Subject to pre-authorisation
Acute Medicines MZN 57 500 per beneficiary per annum
OTC, Including supplements MZN 2 070 per beneficiary per annum
Chronic Medicines *E MZN 149 500 per beneficiary per annum
Chronic Benefits *E
Glucometer and Strips for Insulin Dependant Chronic Members
Subject to Chronic Medicines Limit
Optical Limit - per beneficiary every 12 months MZN 52 325 per beneficiary per annum
Mono- / Bi- / Multifocal lenses
Every 12 months
MZN 25 875 per beneficiary per annum
Frames
Every 12 months
MZN 23 000 per beneficiary per annum
Eye Test
Every 12 months
MZN 2 300 per beneficiary per annum
Refractive surgery
Every 12 months
Subject to Optical Limit

SPECIAL BENEFITS Platinum 2

Repatriation of mortal remains Included
24-hour health advice line Included
Wellness Program Included (HIV / AIDS wellness and management program)

Antenatal Benefit*
Members have to register on a maternity program to qualify for these
benefits

*E = Enrolment Required
*P = Pre-Authorisation Required
*R = Referral by GP or Specialist required
*D = Donor not covered
*L = Lifetime benefit
*D2 = Donor only covered if donor is member of Momentum
Mozambique

Monthly Contributions Platinum 2

Description Corp
Main member 6,400
Adult dependant 5,115
Child dependant 2,670
Special dependant(Parents) 10,675
 COUNTRY MOZAMBIQUE
Cover Area MOZAMBIQUE & RSA
Benefit Year July 2017 - June 2018
PRODUCT Platinum 3
Overall limit In Patient (IP)
No overall annual hospital limit
Benefits payable at 300% of
agreed tariff (Mozambique Price List)
Hospitalisation
(General medical and surgical wards)
Subject to overall IP Limit
Hospitalisation
(Executive/Private Ward))
No Benefits
Hospitalisation
(High Care and ICU)
10 days per beneficiary per annum
Specialists and General Practitioners Subject to overall IP Limit
Theatre Costs Subject to overall IP Limit
Ward and Theatre medicines Subject to overall IP Limit
Major Disease Benefit (MDB) Subject to overall IP Limit
Oncology Subject to MDB
MZN 575 000 per family per annum
Subject to enrolment on oncology program
Organ Transplants *D Subject to MDB MZN 575 000 per family per annum
Organ Transplants *D2 - donor MZN 517 500 per family per annum
Chronic Dialysis- Subject to MDB MZN 517 500 per family per annum
HIV Programme Subject to overall IP Limit
Motor Vehicle Accident Subject to MDB Subject to overall IP Limit
Step Down/Rehabilitation*P MZN 172 500 per family per annum
Medicines to take home Subject to overall IP Limit
Appliances Subject to overall IP Limit
Specialised Radiology
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Pathology Subject to overall IP Limit
Radiology Subject to overall IP Limit
Maxillofacial Surgery Subject to overall IP Limit
Dental Surgery (subject to conditions) Subject to overall IP Limit
Maternity Subject to overall IP Limit
Neonatal, including neonatal ICU and related costs 10 days per beneficiary per annum
Internal and external prosthesis MZN 178 250 per family per annum
Physiotherapy *R Subject to overall IP Limit
Psychiatric hospitalisations 7 days per beneficiary per annum
Addictive conditions & disorders *L 10 days per beneficiary per annum
Circumcision per beneficiary
Age < 15 subject to overall IP Limit
Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Ambulance Services (In Country Only) Subject to overall IP Limit
Air/Cross Borders Evacuation Subject to overall IP Limit
Overall limit Out Patient (OP) MZN 152 950 per beneficiary per annum
Consultations Limit 11 visits per member per annum
GP Consultations Subject to Consultations limit
Specialists Consultations Subject to Consultations limit
Antenatal Benefit* Subject to overall OP Limit
Antenatal Consultations 4 Visits
Ultrasounds 2 Scans
Pathology
1 Full blood count, 1 Elisa test,
ARV syrup for new born
Procedures MZN 19 838 per beneficiary per annum
Pathology Subject to Procedures Limit
Radiology Subject to Procedures Limit
HIV / AIDS Benefit *E
Anti-retroviral therapy
Pathology Tests
Wellness program
Basic Dentistry MZN 14 548 per beneficiary per annum
Advanced Dentistry*P
Orthodontics not covered for age > 18
No Benefit
Physiotherapy *R MZN 5 750 per beneficiary per annum
Auxiliary services *R
No benefit
Psychology No benefit
Acute Medicines MZN 23 575 per beneficiary per annum
OTC, Including supplements MZN 2 070 per beneficiary per annum
Chronic Medicines *E MZN 50 600 per beneficiary per annum
Chronic Benefits *E
Glucometer and Strips for Insulin Dependant Chronic Members
Subject to Chronic Medicines Limit
Optical Limit - per beneficiary every 12 months MZN 17 710 per beneficiary per annum
Mono- / Bi- / Multifocal lenses
Every 12 months
MZN 8 625 per beneficiary per annum
Frames
Every 12 months
MZN 7 475 per beneficiary per annum
Eye Test
Every 12 months
MZN 1 610 per beneficiary per annum
Refractive surgery
Every 12 months
Subject to Optical Limit

SPECIAL BENEFITS PLATINUM OPTION 3

Repatriation of mortal remains Included
24-hour health advice line Included
Wellness Program Included (HIV / AIDS wellness and management program)

Antenatal Benefit*
Members have to register on a maternity program to qualify for these
benefits

*E = Enrolment Required
*P = Pre-Authorisation Required
*R = Referral by GP or Specialist required
*D = Donor not covered
*L = Lifetime benefit
*D2 = Donor only covered if donor is member of Momentum
Mozambique

Monthly Contributions Platinum 3

Description Corp
Main member 4,480
Adult dependant 3,735
Child dependant 2,135
Special dependant(Parents) 7,080
 COUNTRY MOZAMBIQUE
Cover Area MOZAMBIQUE & RSA
Benefit Year July 2017 - June 2018
PRODUCT Bronze 1
Overall limit In Patient (IP)
MZN 4 508 000 per beneficiary per annum Benefits payable at 100% of
agreed tarrif (Mozambique price list)
Hospitalisation
(General medical and surgical wards)
MZN 1 150 000 per hospital episode
Hospitalisation
(Executive/Private Ward))
No Benefits
Hospitalisation
(High Care and ICU)
10 days per beneficiary per annum
Specialists and General Practitioners Subject to overall IP Limit
Theatre Costs Subject to overall IP Limit
Ward and Theatre medicines Subject to overall IP Limit
Major Disease Benefit (MDB) Subject to overall IP Limit
Oncology Subject to MDB
MZN 575 000 per family per annum
Subject to enrolment on oncology program
Organ Transplants *D Subject to MDB MZN 575 000 per family per annum
Organ Transplants *D2 - donor MZN 517 500 per family per annum
Chronic Dialysis- Subject to MDB MZN 517 500 per family per annum
HIV Programme Subject to overall IP Limit
Motor Vehicle Accident Subject to MDB Subject to overall IP Limit
Step Down/Rehabilitation*P MZN 172 500 per family per annum
Medicines to take home Subject to overall IP Limit
Appliances Subject to overall IP Limit
Specialised Radiology
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Pathology Subject to overall IP Limit
Radiology Subject to overall IP Limit
Maxillofacial Surgery Subject to overall IP Limit
Dental Surgery (subject to conditions) Subject to overall IP Limit
Maternity Subject to overall IP Limit
Neonatal, including neonatal ICU and related costs 10 days per beneficiary per annum
Internal and external prosthesis MZN 178 250 per family per annum
Physiotherapy *R Subject to overall IP Limit
Psychiatric hospitalisations 7 days per beneficiary per annum
Addictive conditions & disorders *L 10 days per beneficiary per annum
Circumcision per beneficiary
Age < 15 subject to overall IP Limit
Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Ambulance Services (In Country Only) Subject to overall IP Limit
Air/Cross Borders Evacuation Subject to overall IP Limit
Overall limit Out Patient (OP) MZN 86 825 per beneficiary per annum
Consultations Limit 10 visits per beneficiary per annum
GP Consultations Subject to Consultations limit
Specialists Consultations Subject to Consultations limit
Antenatal Benefit* Subject to overall OP Limit
Antenatal Consultations 4 Visits
Ultrasounds 2 Scans
Pathology
1 Full blood count, 1 Elisa test,
ARV syrup for new born
Procedures MZN 9 919 per beneficiary per annum
Pathology Subject to Procedures Limit
Radiology Subject to Procedures Limit
HIV / AIDS Benefit *E
Anti-retroviral therapy
Pathology Tests
Wellness program
Basic Dentistry MZN 7 274 per beneficiary per annum
Advanced Dentistry*P
Orthodontics not covered for age > 18
No Benefit
Physiotherapy *R MZN 2 875 per beneficiary per annum
Auxiliary services *R
No Benefit
Psychology No Benefit
Acute Medicines MZN 11 270 per beneficiary per annum
OTC, Including supplements MZN 2 070 per beneficiary per annum
Chronic Medicines *E MZN 25 300 per beneficiary per annum
Chronic Benefits *E
Glucometer and Strips for Insulin Dependant Chronic Members
Subject to Chronic Medicines Limit
Optical Limit - per beneficiary every 12 months MZN 10 925 per beneficiary per annum
Mono- / Bi- / Multifocal lenses
Every 12 months
MZN 5 175 per beneficiary per annum
Frames
Every 12 months
MZN 4 600 per beneficiary per annum
Eye Test
Every 12 months
MZN 1 150 per beneficiary per annum
Refractive surgery
Every 12 months
Subject to Optical Limit

SPECIAL BENEFITS Bronze 1

Repatriation of mortal remains Included
24-hour health advice line Included
Wellness Program Included (HIV / AIDS wellness and management program)

Antenatal Benefit*
Members have to register on a maternity program to qualify for these
benefits

*E = Enrolment Required
*P = Pre-Authorisation Required
*R = Referral by GP or Specialist required
*D = Donor not covered
*L = Lifetime benefit
*D2 = Donor only covered if donor is member of Momentum
Mozambique

Monthly Contributions Bronze 1

Description Corp
Main member 4,265
Adult dependant 3,530
Child dependant 2,025
Special dependant(Parents) 5,140
 COUNTRY MOZAMBIQUE
Cover Area MOZAMBIQUE
Benefit Year July 2017 - June 2018
PRODUCT Bronze 2
Overall limit In Patient (IP) MZN 4 508 000 per beneficiary per annum
Hospitalisation
(General medical and surgical wards)
MZN 1 150 000 per hospital episode
Hospitalisation
(Executive/Private Ward))
No Benefits
Hospitalisation
(High Care and ICU)
10 days per beneficiary per annum
Specialists and General Practitioners Subject to overall IP Limit
Theatre Costs Subject to overall IP Limit
Ward and Theatre medicines Subject to overall IP Limit
Major Disease Benefit (MDB) Subject to overall IP Limit
Oncology Subject to MDB
MZN 575 000 per family per annum
Subject to enrolment on oncology program
Organ Transplants *D Subject to MDB MZN 575 000 per family per annum
Organ Transplants *D2 - donor MZN 517 500 per family per annum
Chronic Dialysis- Subject to MDB MZN 517 500 per family per annum
HIV Programme Subject to overall IP Limit
Motor Vehicle Accident Subject to MDB Subject to overall IP Limit
Step Down/Rehabilitation*P MZN 172 500 per family per annum
Medicines to take home Subject to overall IP Limit
Appliances Subject to overall IP Limit
Specialised Radiology
Subject to overall IP Limit
MRI/CT Scan - 1 scan per body region per beneficiary per annum
Pathology Subject to overall IP Limit
Radiology Subject to overall IP Limit
Maxillofacial Surgery Subject to overall IP Limit
Dental Surgery (subject to conditions) Subject to overall IP Limit
Maternity Subject to overall IP Limit
Neonatal, including neonatal ICU and related costs 10 days per beneficiary per annum
Internal and external prosthesis MZN 178 250 per family per annum
Physiotherapy *R Subject to overall IP Limit
Psychiatric hospitalisations 7 days per beneficiary per annum
Addictive conditions & disorders *L 10 days per beneficiary per annum
Circumcision per beneficiary
Age < 15 subject to overall IP Limit
Age >15 procedure to be performed
in doctors room limited to MZN 34 500 per beneficiary
Ambulance Services (In Country Only) Subject to overall IP Limit
Air/Cross Borders Evacuation Subject to overall IP Limit
Overall limit Out Patient (OP) MZN 86 825 per beneficiary per annum
Consultations Limit 10 visits per beneficiary per annum
GP Consultations Subject to Consultations limit
Specialists Consultations Subject to Consultations limit
Antenatal Benefit* Subject to overall OP Limit
Antenatal Consultations 4 Visits
Ultrasounds 2 Scans
Pathology
1 Full blood count, 1 Elisa test,
ARV syrup for new born
Procedures MZN 9 919 per beneficiary per annum
Pathology Subject to Procedures Limit
Radiology Subject to Procedures Limit
HIV / AIDS Benefit *E
Anti-retroviral therapy
Pathology Tests
Wellness program
Basic Dentistry MZN 7 274 per beneficiary per annum
Advanced Dentistry*P
Orthodontics not covered for age > 18
No Benefit
Physiotherapy *R MZN 2 875 per beneficiary per annum
Auxiliary services *R
No Benefit
Psychology No Benefit
Acute Medicines MZN 11 270 per beneficiary per annum
OTC, Including supplements MZN 2 070 per beneficiary per annum
Chronic Medicines *E MZN 25 300 per beneficiary per annum
Chronic Benefits *E
Glucometer and Strips for Insulin Dependant Chronic Members
Subject to Chronic Medicines Limit
Optical Limit - per beneficiary every 12 months MZN 10 925 per beneficiary per annum
Mono- / Bi- / Multifocal lenses
Every 12 months
MZN 5 175 per beneficiary per annum
Frames
Every 12 months
MZN 4 600 per beneficiary per annum
Eye Test
Every 12 months
MZN 1 150 per beneficiary per annum
Refractive surgery
Every 12 months
Subject to Optical Limit

SPECIAL BENEFITS Bronze 2

Repatriation of mortal remains No Benefit
24-hour health advice line Included
Wellness Program Included (HIV / AIDS wellness and management program)

Antenatal Benefit*
Members have to register on a maternity program to qualify for these
benefits

*E = Enrolment Required
*P = Pre-Authorisation Required
*R = Referral by GP or Specialist required
*D = Donor not covered
*L = Lifetime benefit
*D2 = Donor only covered if donor is member of Momentum
Mozambique

Monthly Contributions Bronze 2

Description Corp
Main member 3,690
Adult dependant 3,035
Child dependant 1,710
Special dependant(Parents) 4,280