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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:

• tariffs claimed by the treating doctor and facility
• chemotherapy according to the type of cancer
• radiotherapy according to the type of cancer
• supportive hardware and consumables (like drip bags, pumps and intra-venous (IV) solutions used during the administration of the chemotherapy)
• supportive medicine given for symptomatic treatment of side-effects
• pathology tests
• pain medicine
• clinically appropriate scans

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:

• 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.

Below are some questions and answers which you and your clients might find useful with regards to the Bestmed Oncology programme:

1. Which conditions are funded from a member’s oncology benefit?

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.

2. Why is there a co-payment on the 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, the member will have to pay the difference.

3. I visited my GP/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 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.

4. Will breast reconstruction or prosthesis after mastectomy be funded from my 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.

5. Will wigs be funded from my oncology benefit?

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

6. Are scans approved for members with cancer?

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.

7. 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 designated service provider (DSP) arrangements.

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

The requested treatment must be pre-authorised and will be considered as PMB treatment, according to the PMB guidelines.

9. Why has my chemotherapy not been approved?

Treatment plans may not be approved for several reasons, including the following:

• The treatment plan falls outside the scope of the ICON treatment protocols and guidelines.
• The medicine in the treatment plan is not registered with the South African Health Products Regulatory Authority (SAHPRA) for the specific cancer or the stage of the cancer, or not at all/unregistered.
• The medicine in the treatment plan is not covered on your specific benefit option, biological/high-cost medicine benefit not available. (Please take note that biological/other high-cost medicine will be considered if it qualifies as PMB level of care and/or clinically appropriate for the specific cancer.)

10. The member has a family history of cancer. Will precautionary measures and tests be paid from the oncology benefit?

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

11. Will genetic testing be funded from the oncology benefit?

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.

12. Why are not all cancer-related medicines funded from the 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 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.

13. 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.

14. 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, may not be covered or limited to the available benefit per Scheme option.

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

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.

16. To have access to a more comprehensive oncology benefit, can I upgrade my plan option?

Yes, with appropriate motivation, upgrades may be approved when required.

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

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

18. Will I be covered if I go into remission?

Yes, your registration on the Oncology programme never lapses.

19. Biological and other high-cost medicine

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:

• Beat1 & Beat1N, Beat2 & Beat2N, Beat3 & Beat3N and Beat4: No benefit available, except where treatment is PMB level of care for a specific cancer and its stage.
• Pace1: No benefit available, except where treatment is PMB level of care for a specific cancer and its stage.
• Pace2: Benefit of R166 132 per beneficiary, subject to pre-authorisation. Additional benefit available where treatment is PMB level of care for a specific cancer and its stage.
• Pace3: Benefit of R332 485 per beneficiary, subject to pre-authorisation. Additional benefit available where treatment is PMB level of care for a specific cancer and its stage.
• Pace4: Biological benefit of R492 077 per beneficiary, subject to pre-authorisation. Additional benefit available where treatment is PMB level of care for a specific cancer and its stage.
• Pulse1: No benefit available, except where treatment is PMB level of care for a specific cancer and its stage.
• Pulse2: Limited to R156 743 per beneficiary, subject to pre-authorisation. Additional benefit available where treatment is PMB level of care for a specific cancer and its stage.

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 oncology@bestmed.co.za and one of our case managers will gladly assist you.