Oncology Disease Management Programme

It is important that, prior to commencing active treatment for cancer, you are registered on the Oncology Disease Management Programme (See Summary of Benefits for applicable benefits and limits per your chosen option).

Who needs to register?

Beneficiaries diagnosed with a positive malignant histology that requires some form of chemotherapy, radiotherapy, hormonal therapy and/or supportive therapy.

How to register

  • After you have been diagnosed with cancer, your Oncologist must fax a treatment plan and the histology results to the Scheme’s Oncology Department on 086 762 4050.
  • Once received by TopMed, the oncology disease manager will review the request in accordance with recognised treatment protocols and guidelines for oncology treatment based on clinical appropriateness, evidence-based medicine and the chosen benefit option. If appropriate, an authorisation is generated and a response is provided to the treating oncologist, who in turn will notify the member.
  • Additional information may be required from the oncologist, such as test results, in order to complete the registration process.

In the event of any changes, renewals and amendments to your treatment plan, please ensure that either you or your treating doctor advise the case manager, to ensure that your authorisation is updated accordingly, subject to approval and available limits.

Overview of TopMed’s Oncology Benefits

Depending on your treatment plan, the following benefits could be included:

  • Chemotherapy, radiotherapy and supportive treatment. This is referred to as an Active Treatment Plan.
  • Materials that are used in the administration of your active treatment, for example drips and needles, covered with the active treatment.
  • Technical planning scans.
  • Hormonal therapy related to your cancer regardless of route, is paid at 100% of the TopMed Tariff.
  • Consultations with your oncologist.
  • Fees charged by accredited facilities.
  • Pathology tests related to your condition during active treatment and after treatment for follow-up as required.
  • Supporting medication for pain and nausea as well, as other medicine used to treat the side effects resulting from the disease, will be covered. Note: Medicine to counteract the side effects of chemotherapy and radiotherapy will be paid according to TopMed’s Oncology Disease Management Programme’s guidelines.
  • Cancer medicine received on discharge from hospital will be limited to seven days’ supply and is paid from risk.
  • External breast prostheses, special bras, stoma products and oxygen are paid from your appliance limit.

What benefits does TopMed provide in respect of cancer treatment?

  • The fees charged by your doctor for administering medication, regardless of whether it is done intramuscularly, sub-cutaneously or intravenously, are paid at 100% of the TopMed Tariff, irrespective of whether or not treatment forms part of hospitalisation.
  • Note: Medicine to counteract the side effects of chemotherapy and radiotherapy will be paid according to TopMed’s Oncology Disease Management Programme’s guidelines.
  • Cancer medicine, chemotherapy and radiotherapy is subject to Disease Management under the care of a medical professional. Please note that benefits may be forfeited if members do not comply with the treatment plan.
  • Cancer medicine received on discharge from hospital will be limited to 7 days’ supply and is subject to available day-to-day benefits.
  • Pathology, x-rays, doctor visits during active treatment, materials and items claimed as materials will also be paid from the member’s major medical benefits.
  • Consultations, pathology and radiology related to cancer will continue to be paid one year after active treatment has been completed.
  • Long-term chronic conditions that develop as a result of chemotherapy and radiotherapy are not covered under this benefit.

Breast Reconstruction

Benefits are allowed in respect of reconstructive surgery after a mastectomy due to proven breast cancer. Benefits will be paid once only for full reconstruction by whichever method, as well as for reduction surgery on the unaffected side for symmetry where indicated as per motivation. Only complications of a true medical nature will be considered for benefits and not failed cosmetic surgery.

The oncology benefits listed above are paid at 100% of the TopMed Tariff subject to the treatment forming part of the Disease Management Programme.