You have cover for treating cancer through our Oncology Programme

• Discovery Oncology Management Programme 0860 627 633
• MMD preauthorisation email pre-authorisations@discovery.co.za
• Oncology preauthorisation email MMD_Oncology@discovery.co.za
• Client Service Centre 0860 627 633
• Oncology preauthorisation fax number 011 539 5417

Discovery 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 received.

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.

The Oncology Benefit is structured according to these treatment tiers.

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 coordinate 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.

As soon as you are diagnosed with cancer, please make sure you contact the DiscoveryCare oncology team on 0860 627 633 to make sure you can be registered onto the Oncology Programme. We will require a copy of your histology or pathology to register you.

If your oncologist charges you a rate higher than the Fund 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.

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 per family per year for all your approved cancer related treatment. 
2. The rand amount covers 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. Full cover for treatment plans that fall within the definition and guidelines of the Prescribed Minimum Benefits.

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 a designated service provider, you may be responsible for co-payments on his or her 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 he or she is a designated service provider.

If you choose to have your treatment within a 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.

Read more about the Naspers Medical Fund’s Oncology Programme.

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 Naspers Medical Fund.
2. If your cancer specialist charges more than the Fund 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 limit per family per year. 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. On the N Option Plus items such as wigs will be paid from your external appliances benefit. This is not covered on the N Option Basic.
5. 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 oncology limit available on your plan.
6. Certain treatments, scans and procedures are subject to our funding protocols and clinical entry criteria.
7. Treatment for osteoporosis is paid from the day-to-day benefits and not from the Oncology Benefit.
8. All claims must have a relevant and correct ICD-10 code for us to pay it from the Oncology Benefit.

What you need to do

If you are diagnosed with cancer, you need to register on 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 option has a limit per family per year for your cancer treatment. It is important that you understand and are aware of any personal financial implications before the costs are incurred.

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 Prescribed Minimum Benefits.

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