Oncology Benefit Management
What is the oncology or cancer benefit?
Bestmed’s various benefit options have specified benefits that define the cover for cancer. Collectively these benefits are called “oncology benefits”. Click here to see a summary of the cancer benefits for all the options.
What types of cancer are covered by this benefit?
The regulations of the Medical Schemes Act define cancers covered under the Bestmed oncology benefits as cancers that are contained in the organ of origin. This means that the cancer has not spread to adjacent organs or to distant parts of the body. Certain types of cancers are not bound to organs such as cancers of the blood system. The oncology benefits may include limited cover for cancers that have already spread in order to provide better management of the patient.
Are there specific limits or exclusions in terms of benefits?
If a biological product or other costly medicine (only applicable to specific benefit options) is approved according to Scheme funding guidelines, an annual monetary limit is applicable. This limit is shown in the benefits and brochures of the various benefit options.
Certain services/procedures are excluded from Oncology benefits.
Brachytherapy for prostate cancer will only be considered, where the funding criteria are met, for cover on the Pace4, Pace3, Pace2 and Pulse2 options. A global fee with a limit of R 91 000 (Ninety one thousand Rand) is applicable.
The benefit summary (see question on “what is the oncology benefit”) gives an overview of what is covered and what is excluded in all the Bestmed options.
What is the basis of the Scheme funding guidelines for cancer?
Bestmed provides oncology benefits applying evidence-based medicine principles and considering affordability to the different benefit options. It has therefore appointed the Independent Clinical Oncology Network (ICON) for all the benefit options as Designated Service Provider (DSP), excluding members on Pulse1, Pace3 and Pace4. Bestmed uses the Standard option of ICON for all members.
Members on Pace3 and Pace4 use the South African Oncology Consortium (SAOC) cancer treatment guidelines. Bestmed uses the SAOC “Tier 1” treatment guidelines and these guidelines form the basis of oncology funding for Pace3 and Pace4. “Tier 2” treatment protocols will only be considered as an extended benefit after “Tier 1” has failed and authorisation has been given.
Members on the Pulse1 option make use of State facilities as their appointed DSP for cancer treatment.
Original medicines, with generic alternatives, are reimbursed according to the Mediscor Reference Price (MRP). For more information click here .
How does one qualify for the oncology benefits?
Only members registered on the oncology programme qualify for cancer benefits. Members must forward a clinical summary of their cancer, as set out by their treating doctor, to register on the programme. This must contain the history, ICD–10 codes, the clinical findings of the doctor as well as the test results confirming the cancer and the specific type of cancer. The proposed treatment plan must be submitted so that the oncology team at Bestmed can approve the appropriate therapy. The easiest format for programme registration is to ask the treating doctor to complete the standard ICON treatment form (or SAOC treatment form for Pace3 and Pace4). Only the benefits stipulated by the Scheme will be funded. These specified benefits include chemotherapy (medicine-based cancer treatment) and radiation treatment. |
