GEMS offers 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, as all oncology treatments require pre-authorisation.
The Oncology Management Programme consists of oncology-related medical advisory services, case management for optimal disease management support, evidence-based guidelines, and follow-up on beneficiary treatment.
Your doctor needs to provide GEMS with a treatment plan, which the oncology management team will review using the appropriate clinical guidelines. A member of the team may contact you and your treating doctor to discuss your treatment if there is further clarity required.
After the treatment plan has been assessed and approved, an authorisation letter will be sent to you and your treating doctor. This letter will contain the treatment authorised, the approved quantities, and the length of time that the authorisation is valid.
Kindly ensure that your doctor advises the oncology management team of any change in your treatment, as your authorisation will then need to be reassessed and updated. This is to ensure that your claims are paid from the correct benefit.
Important points to remember:
Benefits covered:
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Onyx
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Emerald |
Emerald Value |
Ruby |
Beryl |
Tanzanite One |
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Limit of R5621 051 per family per annum. Sub-limit of R3419 769 per family for biological and similar specialised medicines.
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Limit of R473 179 per family per annum. Sub-limit of R321 895 per family for biological and similar specialised medicine |
Limit of R473 179 per family per annum. Sub-limit of R321 895 per family for biological and similar specialised medicine. |
Limit of R425 863 per family per annum. Sub-limit of R312 895 per family for biological and similar specialised medicines. |
Limited to R279 288 /family/year |
Limited to Prescribed Minimum Benefits PMBs. |
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The Oncology benefits below are the same across options
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How to register on the Oncology Management Programme:
Please note:
You will need pre-authorisation for any hospitalisation, specialised radiology (e.g., MRI scans, CT scans, angiography), stoma requirements, private nursing, hospice services or palliative care.
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 the standard of care guidelines. Such standard of care refers to the most accepted treatment in South Africa, using evidence-based medicine principles that would be prescribed for a given cancer at a certain level of its growth and/or spread.
The clinical team 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 year.
Common reasons include the following:
When 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 situation. To assist you in your planning, we refer you to some of the common conditions and medications where funding is limited on the basis that either:
This approach ensures that there will be enough money to pay for effective treatments, if needed.
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.
At GEMS we believe that every one of our members matter. That is why we have prepared the member newsletter to focus on your specific needs.