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Healthcare programmes

Oncology (Cancer) Management Programme

GEMS provides a comprehensive set of benefits for oncology to cover diagnosis, treatment, and palliative care. If you or one of your registered beneficiaries are diagnosed with cancer, it is important to register on the oncology management programme as soon as possible. All oncology treatment requires pre-authorisation.

Once the oncology management team has received your treatment plan from your doctor, your details, disease information, and proposed treatment will be captured. Your treatment plan is reviewed against the SAOC clinical guidelines and, if necessary, a member of the clinical team will contact your doctor to discuss more appropriate or cost-effective treatment alternatives.

After the treatment plan has been assessed and approved, an authorisation letter will be sent to you and your treating doctor. The letter will show the treatment authorised, the approved quantities, and how long the authorisation is valid. 

The Oncology programme provides oncology-related medical advisory services, case management for optimal disease management support and to follow up on beneficiary treatment.

Please make sure that your doctor advises the oncology management team of any change in your treatment, as your authorisation will need to be re-assessed and updated. If you fail to do so, your claims may be rejected or paid from the incorrect benefit as there will not be a matching oncology authorisation.

Requirements for Oncology programme registration:

  • Histology and/or scan report confirming the diagnosis of cancer
  • Completed SAOC form
  • Beneficiaries are registered from the date of diagnosis or date on the histology or scan report
  • The oncology benefits are only activated once registered
  • Registration is for life to allow for a regular check-up even if the cancer is in remission

Benefits covered:

Onyx

Emerald

Emerald Value

Ruby

Beryl

Tanzanite One

Limit of R533 976 per family per annum. Sub-limit of R360 915 per family for biological and similar specialised medicines.

Limit of R406 836 per family per annum. Sub-limit of R276 763 per family for biological and similar specialised medicine

Limit of R406 836 per family per annum. Sub-limit of R276 763 per family for biological and similar specialised medicine.

Limit of R366 154 per family per annum. Sub-limit of R276 763 per family for biological and similar specialised medicines.

Limited to R240 130 /family/year

Limited to PMBs.

The Oncology benefits below are the same across options

  • Chemotherapy
  • Radiotherapy
  • Pain control treatment
  • Hormonal Therapy
  • Oncologist consultations
  • General Radiology
  • Advanced Radiology e.g. PET scans, CT and MRI: example monitoring of treatment response, evaluate metastasis
  • Pathology related to diagnosis

 

How to register on the Oncology Management Programme:

  • On diagnosis, your treating doctor should fax a copy of your treatment plan and a copy of the histology which confirms cancer to 0861 00 4367 or email oncologyauths@gems.gov.za.
  • An oncology case manager will then take the process forward.
  • You may also contact the oncology management team on 0860 00 4367.

Please note:

You will need pre-authorisation for any hospitalisation, specialised radiology (e.g. MRI scans, CT scans, angiography), stoma requirements or private nursing, or hospice services.

Reasons for not funding treatment:

When registering on the oncology management programme, the clinical pre-authorisation team reviews the treatment proposed by your doctor and compares it to what is often referred to as the "standard of care". Such standard of care refers to the most commonly accepted treatment in South Africa  using evidence based medicine principles which  would be prescribed for a given cancer at a certain level of its growth and/or spread. The clinical managers also assess whether there are adequate funds based on your options' benefits limits, as well as how much money may have already been used during the course of the year.

There are various reasons that all or some of the treatment schedule that is being requested by your doctor may not be supported for purposes of payment.

 

Common reasons include the following:

  • The treatment for which an application has been submitted is investigational. This means it has not been tested adequately in the clinical setting in which it is being requested.
  • There are less costly treatments that are likely to achieve the same clinical results.
  • Although the treatment may have some accepted clinical benefits, these are very small. If taken together with the potential toxicity of the drug, as well as the drug's significant costs, funding cannot be justified.
  • Available funds are inadequate.

If you and your doctor follow the standard pre-authorisation process, you will always be informed whether the treatment planned by your doctor will be funded in your personal situation.

To assist you in your planning, we refer you to some of the common conditions and drugs where funding is limited on the basis that either cheaper treatments that are likely to be equally beneficial are available, or that the potential toxicity and cost of the drug cannot be justified in light of only very small expected clinical benefits associated with the treatment.

This approach ensures that there will be enough money to pay for effective treatments, where and if needed. Please note that other treatments not listed here may also not be reimbursed for the reasons listed above.

Click here for the summary of the most common Oncology treatments where funding is limited

Policies not listed here are available on request. If your treating doctor requires further information they may contact the Oncology Management team on 0860 00 4367 or via email at oncologyauths@gems.gov.za.