The Bestmed Oncology programme offers coverage for both Prescribed Minimum Benefits (PMBs) and non-PMB cancer diagnoses.
Bestmed has an outstanding Oncology programme with extensive benefits and support to members diagnosed with cancer to optimise their treatment, and to ensure that they have the necessary cover provided by the Scheme during their time of need.
Bestmed uses protocols and funding guidelines to assist in making funding decisions and review is done on a case by case basis. Each member is important to us and Bestmed provides special attention to each request received.
Members that have been diagnosed with cancer to be registered on the Oncology programme need to forward a clinical summary and histology of their cancer, as set out by their treating doctor. This must contain the clinical history, ICD–10 codes, the clinical findings of the doctor; as well as the test results confirming the specific type of cancer. This registration process results in extensive benefits being authorised and allocated to the member.
These benefits include:
Bestmed has contracted the Independent Clinical Oncology Network (ICON) as our Designated Service Provider (DSP) for the management of members with cancer.
This results in the applications for cancer treatment initially reviewed by ICON’s clinical panel (known as TPRC), which consists of qualified oncologists. This panel reviews each application according to the clinical information provided, the protocol applicable for a specific cancer and the level of treatment applicable to a Scheme option.
The ICON treatment protocols are used as a backbone when funding decisions are made. Members on Pace3 and Pace4 have access to the enhanced ICON protocols (where these are clinically appropriate) whilst the members on other benefit options have access to the standard ICON protocols. Should the prescribed treatment fall outside of the protocols, the Scheme would request a new treatment plan which falls within the protocol. In exceptional cases, a clinical motivation can be submitted by the oncologist for consideration.
Bestmed has clinically trained employees handling each application and uses evidence-based principles when authorisation is given. The Oncology team consists of qualified sisters, a pharmacist, a medical doctor, and a consultant.
It is important to note that:
Below are some questions and answers which you and your clients might find useful with regards to the Bestmed Oncology programme:
Cancer 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 which needs to be sent to the Scheme for registration.
Benign tumours and premalignant conditions do not qualify for funding on the Oncology programme. The diagnosis (ICD-10) code for cancer usually starts with a “C” and is included in the oncology benefit.
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, the member will have to pay the difference.
Yes. Bestmed will fund this if the member is registered for the Oncology programme and the Consultation is related to the cancer. As oncologists specialise in the treatment of cancer, the oncology benefit makes automatic provision for funding of oncologists’ 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 and dermatologists for skin cancer. Always confirm benefits before assuming that a consultation will be funded from the oncology benefit.
Breast reconstruction will be considered for funding after a mastectomy for breast cancer on the cancerous breast.
Bestmed will only consider funding of the symmetrising surgery of the unaffected breast for members on Pace2, Pace3, Pace4 and Pulse2 options. A motivation from the surgeon is required and the procedure will be funded up to a maximum of R36 750 once authorised. Hospital authorisation must be obtained from the hospital pre-authorisation department for approval.
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 forwarded to the Scheme. This is covered from the external appliance benefit – if the external appliance benefit is not available then from the savings/vested savings benefit.
No. The oncology benefit does not make provision for the funding of wigs.
Applicable scans are approved from the available scan benefit.
Additional benefits are available where these are clinically appropriate and are PMB level of care for a specific cancer.
This may include basic radiology (such as sonars or black-and-white X-rays) and specialised radiology (MRI and CT-scans). Pre-authorisation for scans are required before they are done. The doctor can confirm if the tariff codes for these scans are funded before proceeding with the services.
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 designated service provider (DSP) arrangements.
The requested treatment must be pre-authorised and will be considered as PMB treatment, according to the PMB guidelines.
Treatment plans may not be approved for several reasons, including the following:
No. Oncology benefits are limited to members who have been diagnosed with cancer and are registered on the Oncology programme.
The request requires a pre-authorisation process and will be considered if clinically appropriate and according to entry criteria.
Please note: The tests will only be authorised if they have the potential to influence the treatment of the diagnosed cancer.
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 example nausea, pain and inflammation).
Examples of medicines excluded from the oncology benefit include, but are not limited to these, are anti-depressants, proton pump inhibitors and anti-acids for acid reflux, sleeping tablets and anti-anxiety medicines.
Certain services/procedures are excluded from oncology benefits, including (but not limited to) the following:
This benefit will be considered if clinically appropriate or PMB level of care.
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, may not be covered or limited to the available benefit per Scheme option.
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 reference price (MRP) which applies to medicines with generic alternatives.
Yes, with appropriate motivation, upgrades may be approved when required.
Yes, these are evaluated case by case, based on evidence-based principles.
Yes, your registration on the Oncology programme never lapses.
Biological medicines are derived from a living source, for example interferon treatment for advanced melanoma.
Other high cost items include, which are not biologicals, include the so-called “designer” medicines. Biological and other high-cost medicines are limited to the following amounts, unless the treatment is classified as PMB level of care for a specific cancer diagnosis:
Biological/expensive medicine benefits allocated per option:
If you would like to find out more about the Bestmed Oncology programme and its benefits, please visit our website. Alternatively, you can contact us on 012 472 6254/6234 or via email at firstname.lastname@example.org and one of our case managers will gladly assist you.