Oncology

Providing affordable healthcare to all our members

We take into account the total number of members affected by a disease and the potential impact to all the scheme members.

Our dedicated and experienced consultants help members with many aspects of their cancer treatment. They offer support services and access to reliable information on cancer, and what steps a patient can take to fight and manage the disease.

Discovery Health Oncology Contact details
We review cases to ensure that we meet local and international cancer treatment guidelines

Discovery Health consults with the South African Oncology Consortium Utilisation Review Committee (SAOC-URC) to review specific cancer cases. This case review process ensures that our oncology members receive the most appropriate treatment, based on the clinical information given.

The South African Oncology Consortium (SAOC) develops treatment guidelines according to research findings and clinical evidence of cancer medicines and treatments. All treatment guidelines include a unique set of treatment codes that the cancer specialist (oncologist) can prescribe.

Their treatment guidelines are divided into three levels or tiers, namely:
  • Tier 1 – Prescribed Minimum Benefit treatment:
    This is treatment available to all patients in state facilities
  • Tier 2 – Standard treatment:
    This is treatment that is registered for a specific condition and is given as such.
  • Tier 3 – Novel treatment:
  • This includes cancer treatment that may be new, not registered and expensive. Other novel treatments may be a registered drug that is used for a condition for which it is not registered.

Discovery Health’s Oncology Benefit is structured according to these treatment tiers.

About the South African Oncology Consortium

Who they are

The South African Oncology Consortium is a managed care organisation that represents the majority of oncologists (cancer specialists) in the private and public healthcare sectors in South Africa. Specialists from all disciplines in oncology, including radiation oncology, medical and clinical oncology, haematology and paediatricians are members of the consortium.

What they do

The South African Oncology Consortium aims to co-ordinate the way cancer treatment is prescribed through specific treatment guidelines or rules. The treatment guidelines are classified into specific ‘levels’ or ‘tiers’ according to the Prescribed Minimum Benefits, standard treatments and new treatments. The classification is done in line with international standards to accommodate the cost of treatment with members’ oncology benefits. The consortium also acts as a peer-to-peer review body, and ensures that quality care is delivered on a long-term basis.

When you are first diagnosed

As soon as you are diagnosed with cancer, please make sure you contact the DiscoveryCare oncology team on 0860 99 88 77 to make sure you can be registered onto the Oncology Programme. We will require a copy of your histology or pathology to register you.

Professional fees

If your oncologist charges you a rate higher than the Discovery Health rate, you may be charged an amount from your pocket for professional services such as consultations. Please discuss this with your oncologist to understand how this will impact you.

Cover for cancer

The Oncology Benefit provides members cover for approved cancer treatment. To offer members a flexible range of options to fund their cancer treatment, we have structured the benefit to include the following:

1. A specific rand amount for all your approved cancer related treatment. This rand amount will be allocated on a 12-month benefit cycle and differs on each plan. This benefit does not apply to KeyCare Plans.

2. The rand amount covers the chemotherapy, radiotherapy and other treatment prescribed by your cancer specialist .This also includes pathology, radiology, medicine and other cancer-related treatment that is provided by healthcare professionals other than your cancer specialist.

3. Above this amount you will continue to be covered for all approved cancer treatment, but you will be responsible to pay 20% of the costs from your pocket. This does not apply to treatment under the Prescribed Minimum Benefits.

4. Full cover for treatment plans that fall within the definition and guidelines of the Prescribed Minimum Benefits.

5. Access to donor searches for bone marrow transplants, which are funded according to your plan type, clinical protocols and subject to the use of designated Centres of Excellence.

6. Access to PET CT scans, which is subject to benefit confirmation and clinical entry criteria. We cover approved PET CT scans in full at our preferred providers. You will be responsible to pay R2 750 for each scan done at a provider who is not on our preferred provider list. Approved scans will add up to your 12-month rand amount. This benefit does not apply to KeyCare Plans.

Specific rand amount for your cancer treatment provides you with more choice

All approved cancer treatment will add up to the rand amount specific to your plan type.

This allows you flexibility in your treatment choices and gives you more choice.

The Oncology Benefit covers the following treatments that are provided by your cancer specialist and other healthcare providers, up to the specific rand amount:

  • Chemotherapy
  • Radiotherapy
  • Technical planning scans
  • Implantable cancer treatments such as Brachytherapy and Gliadel® wafers
  • Hormonal therapy relating to your cancer
  • Consultations with your cancer specialist
  • Fees that are charged by the treatment facility
  • Specific blood tests related to your condition
  • Radiology requested by your cancer specialist, which includes:
    • Basic black and white x-rays
    • CT and MRI scans related to your cancer
    • PET CT scans (subject to benefit confirmation and approval according to clinical entry criteria)
    • Nuclear scans
    • Ultrasound, isotope or bone scans
    • Other specialised scans, eg gallium scan
    • Scopes such as brochoscopy, colonoscopy and gastroscopy that are used in the management of your cancer
  • External breast prosthesis and special bras
  • Drainage of lymph nodes
  • Stoma products
  • Materials that are used in the administration of your treatment, for example drips, needles, syringes, pumps and hydration
  • Medicine to treat pain, nausea and depression as well as other medicine used to treat the side effects of your cancer treatment (except schedule 0, 1 and 2 medicine).

All the treatments listed above will add up to the specific rand amount. If your treatment goes over the rand amount, you will be responsible to pay 20% of the costs from your pocket. You may be responsible for a higher co-payment if your healthcare provider charges more than the Discovery Health Rate.

This does not apply to the Prescribed Minimum Benefits treatment, which is covered in full on all Health Plans in accordance with our clinical guidelines.

To find out what the specific rand amounts for each plan type is, refer to the section Benefits available for your plan type. This rand amount is calculated on a 12-month benefit cycle and does not necessarily begin in January of the benefit year.

Other needs related to your condition and treatment that are not listed above may be funded from your day-to-day benefits, for example wigs.

All cancer treatments have to be approved and will be subject to managed care criteria.

 
Treatment requests authorised in 2011

For treatment that we have authorised in 2011 but which continues into 2012, the following applies:

Your authorisation will remain valid until the end of your unique specified end-date

From 1 January 2012 your treatment costs will count towards your 12-month rand amount for the benefit cycle.

Any special oncology benefit limits in 2010 do not carry over for 2012. Examples include the Specialty Medical Technology Benefit.

 
Bone marrow transplants

Discovery Health will provide you with access to funding for local searches, or local and international searches on certain plans, for suitable donors for bone marrow transplants if these adhere to our protocols and Centres of Excellence.

If you choose not to use our Centres of Excellence you will have a limit of R1 million for the entire transplant cost, including the search and actual transplant costs.

Bone marrow transplantation costs do not add up to the 12-month rand amount for cancer treatment as detailed above

 
How to get the most out of the benefits available to you

You can choose where to have your cancer treatment. However if you choose to see a cancer specialist who is not part of our designated service providers, you may be responsible to pay shortfall on the accounts.

What you need to do to have 100% cover for your cancer treatment

Tell us about where you’ll be having your treatment and who your treating doctor is and we’ll confirm if they are one of our designated service providers.

If you choose to have your treatment within our designated service provider, there will be no shortfall in payment. Remember that any plan specific benefits apply in this case, such as deductibles on Priority Plans and co-payments for endoscopies.

 
What you need to know before your treatment

1. We will only fund your cancer treatment from the Oncology Benefit if your treatment plan has been approved by Discovery Health.

2. If your cancer specialist charges more than the Discovery Health Rate, you may be responsible for paying the difference from your pocket for professional services such as consultations.

3. All costs related to your approved cancer treatment will count towards the 12-month rand amount. This includes chemotherapy, radiotherapy and other treatment prescribed by your cancer specialist as well as pathology, radiology, medicine and other cancer-related treatment that is provided by healthcare professionals other than your cancer specialist.

4. We will cover any costs that are more than the rand amount allocated to you plan at 80% of the Discovery Health Rate. You will need to pay the rest of the costs yourself. You may therefore be responsible for an amount higher than 20% if your healthcare provider charges more than the Discovery Health Rate.

5. The rand amount for each plan is limited to a 12-month period and any funds left will not be carried over into the following 12-month period.

6. Certain items such as Brachytherapy and Giladel wafers® that are administered in hospital will add up to your 12-month rand amount.

7. Certain items such as wigs will be paid from your day-to-day benefits, if available.

8. Newly registered medicine and treatments usually enter the market at a high price. The high cost of these treatments poses a significant financial challenge to healthcare funders. Any newly registered medicine and treatment will be funded up to the 12-month rand amount available on your plan.

9. Certain treatments, scans and procedures are subject to our funding protocols and clinical entry criteria.

10. Treatment for osteoporosis is paid from the day-to-day benefits and not from the Oncology Benefit.

11. All claims must have a relevant and correct ICD-10 code for us to pay it from the Oncology Benefit.

 
What this benefit may expose you to

1. We do not pay unregistered medicine and treatments, as detailed in the Discovery Health Medical Scheme rules.

2. If you choose to visit a service provider who is not one of our designated service providers, you will be responsible to pay any shortfall from your pocket.

3. You will be responsible to pay 20% of your treatment costs from your pocket once your accumulating treatment costs have reached the 12-month rand amount specific to your plan.

4. Other needs related to your condition and treatment not covered from the Oncology Benefit will be paid from the day-to-day benefits, for example wigs.

 
What you need to do

If you are diagnosed with cancer, you need to register on Discovery Health’s Oncology Programme to have access to the Oncology Benefit.

To register, you or your treating doctor must send us details of your diagnosis and the test results that confirm your diagnosis.

If you need cancer treatment, your cancer specialist should send us your treatment plan for approval before starting with the treatment.

Please remember that your chosen Heath Plan has a 12-month rand amount available for your cancer treatment. It is important that you understand and are aware of any personal financial implications before the costs are incurred.

 
Benefits available for your plan type
 
Executive Plan

1. R400 000 cover for a 12-month benefit cycle for the chemotherapy, radiotherapy and other treatment prescribed by your cancer specialist as well as pathology, radiology, medicine and other cancer-related treatment that is provided by healthcare professionals other than your cancer specialist. Once your cancer treatment costs go over this limit, you will need to pay 20% of the costs of all further treatment from your pocket. You may be responsible for a higher co-payment if your healthcare provider charges more than the Discovery Health Rate.

2. Full cover for treatment plans that falls within the guidelines and protocols for the Prescribed Minimum Benefits within our designated service providers once the R400 000 rand limit is reached.

3. Access to local and international bone marrow donor searches and approved transplant treatment within our Centres of Excellence. This treatment is unlimited, however, if you choose to not use our Centres of Excellence, a R1 million limit will apply to all costs related to the bone marrow transplant.

4. Bone density scans will be paid from the available funds in your Medical Savings Account and Above Threshold Benefit.

5. Wigs will be paid from the available funds in your Medical Savings Account and Above Threshold Benefit, subject to the External Medical Items limit of R45 500.

 
Comprehensive Series

1. R400 000 cover for a 12-month benefit cycle for the chemotherapy, radiotherapy and other treatment prescribed by your cancer specialist as well as pathology, radiology, medicine and other cancer-related treatment that is provided by healthcare professionals other than your cancer specialist. Once your cancer treatment costs go over this limit, you will need to pay 20% of the costs of all further treatment from your pocket. You may be responsible for a higher co-payment if your healthcare provider charges more than the Discovery Health Rate.

2. Full cover for treatment plans that falls within the guidelines and protocols for the Prescribed Minimum Benefits within our designated service providers once the R400 000 rand limit is reached.

3. Access to local and international bone marrow donor searches and approved transplant treatment within our Centres of Excellence. This treatment is unlimited, however, if you choose to not use our Centres of Excellence, a R1 million limit will apply to all costs related to the bone marrow transplant.

4. Bone density scans will be paid from the available funds in your Medical Savings Account and Above Threshold Benefit.

5. Wigs will be paid from the available funds in your Medical Savings Account and Above Threshold Benefit, subject to the External Medical Items limit of:

R45 500 on Classic Comprehensive and Classic Delta Comprehensive, and R30 250 on Essential Comprehensive and Essential Delta Comprehensive.

 
Priority Series

1. R200 000 cover for a 12-month benefit cycle for the chemotherapy, radiotherapy and other treatment prescribed by your cancer specialist as well as pathology, radiology, medicine and other cancer-related treatment that is provided by healthcare professionals other than your cancer specialist. Once your cancer treatment costs go over this limit, you will need to pay 20% of the costs of all further treatment from your pocket. You may be responsible for a higher co-payment if your healthcare provider charges more than the Discovery Health Rate.

2. Full cover for treatment plans that falls within the guidelines and protocols for the Prescribed Minimum Benefits within our designated service providers once the R200 000 rand limit is reached.

3. Access to local and international bone marrow donor searches and approved transplant treatment within our Centres of Excellence. This treatment is unlimited, however, if you choose to not use our Centres of Excellence, a R1 million limit will apply to all costs related to the bone marrow transplant.

4. Bone density scans will be paid from the available funds in your Medical Savings Account and limited Above Threshold Benefit.

5. Wigs will be paid from the available funds in your Medical Savings Account and limited Above Threshold Benefit, subject to the External Medical Items limit of:

R30 250 on Classic Priority, and R20 500 on Essential Priority.

 
Saver Series

1. R200 000 cover for a 12-month benefit cycle for the chemotherapy, radiotherapy and other treatment prescribed by your cancer specialist as well as pathology, radiology, medicine and other cancer-related treatment that is provided by healthcare professionals other than your cancer specialist. Once your cancer treatment costs go over this limit, you will need to pay 20% of the costs of all further treatment from your pocket. You may be responsible for a higher co-payment if your healthcare provider charges more than the Discovery Health Rate.

2. Full cover for treatment plans that falls within the guidelines and protocols for the Prescribed Minimum Benefits within our designated service providers once the R200 000 rand limit is reached.

3. Access to local and international bone marrow donor searches and approved transplant treatment within our Centres of Excellence. This treatment is unlimited, however, if you choose to not use our Centres of Excellence, a R1 million limit will apply to all costs related to the bone marrow transplant.

4. Bone density scans will be paid from the available funds in your Medical Savings Account.

5. Wigs will be paid from the available funds in your Medical Savings Account.

 
Core Series

1. R200 000 cover for a 12-month benefit cycle for the chemotherapy, radiotherapy and other treatment prescribed by your cancer specialist as well as pathology, radiology, medicine and other cancer-related treatment that is provided by healthcare professionals other than your cancer specialist. Once your cancer treatment costs go over this limit, you will need to pay 20% of the costs of all further treatment from your pocket. You may be responsible for a higher co-payment if your healthcare provider charges more than the Discovery Health Rate.

2. Full cover for treatment plans that falls within the guidelines and protocols for the Prescribed Minimum Benefits within our designated service providers once the R200 000 rand limit is reached.

3. Access to local and international bone marrow donor searches and approved transplant treatment within our Centres of Excellence. This treatment is unlimited, however, if you choose to not use our Centres of Excellence, a R1 million limit will apply to all costs related to the bone marrow transplant.

4. Bone density scans will be for your own costs.

5. Wigs will be for your own cost.

 
KeyCare Series

1. Cover for the chemotherapy, radiotherapy and other treatment prescribed by your cancer specialist as well as pathology, radiology, medicine and other cancer-related treatment that is provided by healthcare professionals other than your cancer specialist. This treatment must be in line with agreed protocols and subject to treatment at a KeyCare Oncology designated network.

2. Full cover for treatment plans that falls within the definition of the Prescribed Minimum Benefits within our designated service provider, which is the State.

3. Access to local bone marrow donor searches. These costs are paid according to your plan type, clinical protocols and subject to Centres of Excellence.

4. Bone density scans will be for your own costs.

5. Wigs will be for your own costs

Prescribed Minimum benefits

Prescribed Minimum Benefit is a set of minimum benefits which, by law, must be provided to all medical scheme members. It includes the provision of diagnosis, treatment and care costs of defined set of conditions. Medical schemes have to pay these minimum treatments in full from the risk benefits.

Schemes, on their part, are encouraged to define Designated Service Provider (DSP) networks, apply evidence-based protocols and develop formularies or medicine lists to manage PMBs.

Your condition may be classified as a Prescribed Minimum Benefit condition, however only certain treatment protocols are available for funding from the PMB risk benefit.

Only when a member chooses to receive treatment outside of the designated service provider, protocols and formularies, does the scheme have the right to apply co-payments.

Please ensure you confirm benefits for all your cancer treatment, whether in- or out-of-hospital, with us.

We will pay the claims as a Prescribed Minimum Benefit if it has a valid ICD-10 code.

Download the summary of how Discovery Health covers the Prescribed Minimum Benefits and our Designated Service Providers.

Out-of-hospital cancer treatment as part of a Prescribed Minimum Benefit

Cancer-treating specialists

All Health Plans except KeyCare

Any oncologist participating in our direct payment arrangement or who is contracted with the State

KeyCare

Any specific oncology provider who is contracted with the State


Cancer-treating GPs

All Health Plans except KeyCare

Any GP who is on the Discovery Health GP Network and is a member of the South African Oncology Consortium (SAOC)

KeyCare

KeyCare Network GP who is a member of the South African Oncology Consortium (SAOC)
 
Cancer treatment done in hospital as part of a Prescribed Minimum Benefit

Medical and surgical management

When you are admitted to hospital for medical or surgical treatment for your cancer, you need to ensure that your surgeon or treating doctor, anaesthetist and the hospital are within our designated service providers.

Hospital

All Health Plans except KeyCare

Any KeyCare Network hospital or a state hospital that is contracted with Discovery Health.

Where a member on the Classic or Essential Coastal or Delta network options choose a facility in the Coastal or Delta Hospital Network, that facility will constitute a designated service provider.

KeyCare

Any KeyCare Network hospital or a state hospital that is contracted with Discovery Health.

Specialist consultations

Executive Plan and Classic Series

All specialists participating in our direct payment arrangements and/or any specialist working in a state hospital who is contracted with Discovery Health.

You benefit from access to a broad range of specialists whom we pay in full.

KeyCare

Any specialist participating in a KeyCare Specialist Network, except where there is no KeyCare specialist, in which case any specialist practising in a KeyCare Network Hospital who participates in our direct payment arrangement and/or any specialist working in a state hospital who is contracted with Discovery Health.

All other Health Plans

All practising specialists participating in our direct payment arrangements, and/or any specialist working in a state hospital who is contracted with Discovery Health.
 
Cancer treatment done by a healthcare professional other than a cancer specialist as part of a Prescribed Minimum Benefit

This refers to specialist ancillary services such as cardiologists, dermatologists, gynaecologists or urologist, for example.

How we’ll pay the treating specialist

Executive Plan and Classic Series

All specialists participating in our direct payment arrangements and/or any specialist working in a state hospital who is contracted with Discovery Health.

You benefit from access to a broad range of specialists whom we pay in full.

KeyCare

Any specialist participating in a KeyCare Specialist Network, except where there is no KeyCare specialist, in which case any specialist practising in a KeyCare Network Hospital who participates in our direct payment arrangement and/or any specialist working in a state hospital who is contracted with Discovery Health.

All other Health Plans

All practising specialists participating in our direct payment arrangements, and/or any specialist working in a state hospital who is contracted with Discovery Health.

Diagnostic work-up as part of a Prescribed Minimum Benefit

This refers to the out-of-hospital tests and investigations you need to have done for the diagnosis of your condition.

How we’ll pay the tests and investigations done for the diagnosis of your condition

All Health Plans

If your chosen Health Plan does not cover the costs of the diagnostic work-up adequately and you require these to be covered as a Prescribed Minimum Benefit, you may appeal for this by completing and sending us an out-of-hospital PMB appeal form (OH PMB form).