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Care

Oncology

Oncology is a branch of medicine which deals with the prevention, diagnosis and treatment of cancer. A medical professional who practices oncology is an oncologist.

Types of cancer:

  • Cancer which affects non-solid organs and systems
  • Cancer of solid organs

The Oncology care programme

Bestmed’s various healthcare options have specified benefits that define the cover for cancer. These benefits are called oncology benefits.

Bestmed provides oncology benefits, applying evidence-based medicine principles and considering affordability across the different benefit options.

  • All types of cancer are covered under the Bestmed Oncology care programme
  • Bestmed has clinically qualified staff, including qualified nurses, pharmacists and medical doctors, who are available on site to review applications

We have appointed the Independent Clinical Oncology Network (ICON) as designated service provider (DSP) for oncology care for all our healthcare options. Members on Pace3 and Pace4 have access to the enhanced ICON protocols where it‘s clinically appropriate, whilst the other options have access to the standard ICON protocols.

Members registered on the oncology programme qualify for cancer benefits. Members must forward a clinical summary and histology 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.

Benefits

Oncology care programme benefits

  • Access to benefits and services which form part of the treatment protocol of the specified designated service provider (DSP): ICON
  • Oncology treatment which includes chemotherapy, radiotherapy, certain pathology and certain consultations
  • Certain supportive medicines in the Bestmed oncology formulary
  • Should the prescribed treatment fall outside of the protocols, a clinical motivation can be submitted by the oncologist for consideration

Biological and other high-cost medicine

Biological medicines are derived from a living source, for example interferon treatment for advanced melanoma. Biological and other high-cost medicines are limited to the following amounts:

Biological benefits allocated per option

  • Beat1 & Beat1N, Beat2 & Beat2N, Beat3 & Beat3N and Beat4: No benefit
  • Pace1: No benefit
  • Pace2: Limited to R166 132 per beneficiary, subject to pre-authorisation
  • Pace3: R332 485 per beneficiary, subject to pre-authorisation
  • Pace4: Limited to R492 077 per beneficiary, subject to pre-authorisation
  • Pulse1: PMBs only as per funding protocol
  • Pulse2: Limited to R156 743 per beneficiary, subject to pre-authorisation

Please refer to the oncology benefits table for a detailed description.

Register

Register to access the Oncology programme and associated benefits

  • All services must be pre-authorised by Bestmed
  • Services are rendered by Bestmed’s preferred providers
  • The services must fall within Bestmed’s funding guidelines
  • If you would like to find out more about the oncology programme and benefits you can contact us on  +27 (0)12 472 6254 or +27 (0)12 472 6234 or via email oncology@bestmed.co.za and one of our case managers will gladly assist you. Alternatively, you can download the Managed Care Guide here

 

Downloads

Documents

FAQs

Are scans approved for members with cancer?

A range of scans and blood tests is approved from the available scan and pathology benefits and PMBs where clinically appropriate depending on the type of cancer you are registered for. A group of specific services, directly related to the specific type of cancer, are authorised for payment. This may include basic radiology (such as sonars or black-and-white X-rays) or blood tests (such as liver function tests and blood counts). Pre-authorisation for scans and additional tests are required before they are done. Your doctor can confirm if the tariff codes for these scans and tests are funded before proceeding with these services. CT scans, PET scans and nuclear scans will be considered for funding from available benefit/PMBs if they are on a PMB level of care and clinically appropriate.

Will breast reconstruction or prosthesis after mastectomy be funded from my oncology benefit?

Breast reconstruction may be considered for funding only after a mastectomy for breast cancer on the cancerous breast. Bestmed will consider funding the symmetrising surgery of the unaffected breast on the Pace2, Pace3, Pace4 and Pulse2 options, with motivation from the doctor, dependent on the cost of the procedure, up to a maximum of R36 750 where appropriate and pre-authorised. Hospital authorisation must be obtained from the pre-authorisation department for approval, subject to funding protocols and guidelines. After a mastectomy a member may apply for a breast prosthesis that is inserted into her bra to provide shape where the breast used to be. A doctor’s motivation and quotation may be sent to the Scheme. Only the prosthetic insert may be funded from the appliance benefit and not the special bra.

I visited my FP/specialist regarding my cancer. Will it be funded from my oncology benefit?

Yes. Bestmed will fund this if the member is registered for the oncology programme and the consultation was related to the cancer. As oncologists specialise in the treatment of cancer the oncology benefit makes provision for funding of oncologist consultations. Certain specialist visits may be funded from the oncology benefit depending on the type of cancer you are registered for. For example, urologists for bladder cancer, dermatologists for skin cancer, etc. Always confirm benefits before assuming that a consultation will be funded from the oncology benefit.

Is Hospice funded?

Hospice authorisation will be considered by the hospital pre-authorisation department. Palliative care is funded at 100% Scheme tariff. Subject to specific limits per option and pre-authorisation and DSPs.

A member needs to go for physiotherapy or lymph drainage. Will it be funded from the oncology benefit?

The requested treatment needs to be pre-authorised and will be considered as a PMB if clinically appropriate.

Which conditions are funded from my oncology benefit?

Cancer (malignant tumours and malignant haematological/blood conditions) confirmed by a laboratory report will qualify for registration on the oncology programme. Normally a tissue sample is collected during a biopsy procedure and sent for evaluation by pathologists. The findings of the diagnosis will be noted on a histology report. Benign tumours and premalignant conditions don’t qualify for funding on the oncology programme. The diagnosis (ICD-10) code for cancer usually starts with a “C” and may be included in the oncology benefit. Codes for benign conditions mostly start with a “D” and are not funded from the oncology benefit as they are not cancerous.

Why do I have a co-payment on my consultation/procedure?

Oncology benefits are funded up to 100% of the Bestmed Scheme tariff. If a non-DSP (thus non-ICON) doctor charges more than the Scheme tariff you will have to pay the difference.

Why has my chemotherapy not been approved?

Bestmed provides oncology benefits applying evidence-based medicine principles and considering affordability to the different benefit options. Treatment plans may not be approved for several different reasons, including the following:

  • The treatment plan falls outside the scope of ICON treatment protocols and guidelines
  • The medicine in the treatment plan is not registered with the South African Medicine Control Council for the treatment of the specific cancer
  • The medicine is not registered for use in the South African market by the Medicine Control Council or
  • The medicine in the treatment plan is not covered on your specific benefit option, biological and other high-cost medicine, etc. (Please take note that biological and other high-cost medicine will be considered if it’s on a PMB level of care and/or clinically appropriate for the specific cancer.)
  • The member has a family history of cancer

Will wigs be funded from my oncology benefit?

No. The oncology benefit does not make provision for the funding of wigs and related items.

Will precautionary measures and tests be paid from the oncology benefit?

No. Oncology benefits are limited to patients who have already been diagnosed with cancer and are registered on the oncology programme.

Will genetic testing be funded from the oncology benefit?

The request will need to go through the pre-authorisation process and will be considered if clinically appropriate. Please note: The tests will only be authorised if they have the potential to influence the treatment of the diagnosed cancer.

Why isn’t all cancer-related medicine funded from my oncology benefit?

The oncology benefit provides funding for chemotherapy and radiotherapy – treatment directly linked to treating and minimising the progression of the cancer itself. Bestmed makes use of formularies for certain additional supportive medicines (for nausea, pain, inflammation, etc.). Medicines which are excluded from the oncology benefit include anti-depressants, proton pump inhibitors for acid reflux, sleeping tablets, anti-anxiety medicines, etc.

Are there specific limits or exclusions in terms of benefits?

Certain services/procedures are excluded from oncology benefits, including (but not limited to) the following:

  • 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. This benefit will be considered if clinically appropriate or PMB level of care 
  • Specialised radiology services, including CT scans, PET scans and nuclear scans, will be considered if clinically appropriate and/or PMB level of care, assessed on a case-by-case basis
  • Only benefits as stipulated and authorised by the Scheme will be funded in accordance with the specific benefit option

Is there an annual oncology limit for registered treatment?

There is no limit for appropriate and in protocol pathology and consultations. Biologicals and other high cost medicine, where this treatment is not PMB level of care, can be excluded or limited to the available benefit per Scheme option.

Are there co-payments or shortfalls that a member may experience after their treatment plan has been approved by ICON?

Biologicals and other high cost medicine, where this treatment is not PMB level of care, will be limited to the available benefit per Scheme option. Bestmed also applies a generic Mediscor reference price (MRP) which applies to medicines with generic alternatives. To access the extended oncology benefit, can I upgrade my plan option? Yes, with appropriate motivation upgrade may be approved on request.

Can prescribed treatment outside of the funding guidelines be reviewed for funding?

Yes, these are evaluated case by case, based on evidence-based principles.

Will I be covered if I go into remission?

Yes, your registration on the oncology programme never lapses.