A colorectal cancer diagnosis activates a fast-moving clinical pathway — surgery planning, staging scans, biomarker testing, and oncology referral often happen within weeks. Alongside the medical decisions, you need to understand what your medical aid will cover, where the gaps are, and what to do right now.
Does My Medical Aid Have to Cover This?
Yes. Colorectal cancer is a Prescribed Minimum Benefit (PMB). Your medical aid is legally required to fund diagnosis, surgery, chemotherapy, and radiation therapy. They cannot refuse coverage.
What PMB does not guarantee: - Payment of specialist fees at your doctor's rate (specialist shortfalls are common and significant) - Funding of bevacizumab, cetuximab, or pembrolizumab without an exceptional-needs authorisation - Automatic funding of biomarker tests (KRAS, MSI testing) — these vary by scheme
The First Calls to Make
Call 1: Oncology case management Contact your medical aid's oncology case management line and register your diagnosis. Request a dedicated case manager. This is the single most effective administrative step you can take — it ensures pre-authorisations are coordinated and claims are correctly classified as PMB.
Call 2: Your colorectal surgeon's practice manager Before surgery, ask explicitly whether the surgeon bills within medical aid tariff or above it. If above tariff, ask for their billing rate (typically expressed as a percentage of the medical aid tariff, e.g., "200% of tariff"). This lets you estimate your shortfall in advance.
Biomarker Testing: Do This Before Systemic Treatment Starts
If your cancer is Stage III or IV and systemic chemotherapy is planned, you need KRAS/NRAS mutation testing and MSI/MMR testing before treatment decisions are finalised. These tests determine: - Whether anti-EGFR therapy (cetuximab) is an option (requires KRAS/NRAS wild-type) - Whether you qualify for pembrolizumab immunotherapy (requires MSI-H/dMMR status)
If your scheme does not fund these tests, the cost is R3,000–R14,000 out of pocket. Do not defer these tests — the results are clinically essential and some treatment windows have time sensitivity.
Understanding Your Surgical Options and Shortfall Risk
Colorectal surgery is a major procedure with significant specialist shortfall risk:
Colorectal surgeon: Bills above tariff in the majority of SA private hospital cases. Shortfall on a major resection: R20,000–R70,000 depending on procedure complexity.
Anaesthesiologist: Bills above tariff at virtually every major procedure. Shortfall: R5,000–R20,000 per procedure.
Laparoscopic/robotic technique premium: If your surgeon uses minimally invasive technique and your scheme funds only open-surgery rates, you carry the technique premium.
Prior authorisation is essential before surgery. Without it, the hospital facility claim may be rejected. Get this in writing — a phone authorisation number is not enough; request written confirmation.
Chemotherapy: What to Expect From Your Scheme
Stage III adjuvant chemotherapy (FOLFOX or CAPOX) is the PMB-minimum treatment standard. Your scheme must fund this.
Chemotherapy infusion raises additional questions: - Where is chemotherapy administered? Some schemes restrict infusions to hospital day wards; others allow approved outpatient oncology centres (which may be more convenient). Confirm with your scheme. - Oral chemotherapy (capecitabine): Some plans process this differently from IV chemotherapy — it may fall under your day-to-day drug benefit rather than the oncology benefit. Confirm how your specific plan classifies it.
If You're Stage IV: Exceptional-Needs Medicines
For metastatic disease, bevacizumab and pembrolizumab are the most common exceptional-needs requests:
- Bevacizumab (Avastin): Anti-VEGF targeted therapy. Monthly cost ~R22,000–R28,000. Requires exceptional-needs application. A well-documented application includes staging, KRAS/RAS test results, and NCCN guideline references.
- Pembrolizumab (Keytruda): For MSI-H/dMMR tumours. Monthly cost ~R50,000–R60,000. Requires exceptional-needs plus confirmed MSI-H/dMMR result. Approval rates improve substantially when the MSI-H/dMMR molecular confirmation is included in the motivation.
If an exceptional-needs application is declined, request written reasons and ask your oncologist to submit an enhanced motivation. Escalate to the Council for Medical Schemes if needed.
Stoma Planning (If Applicable)
If your surgery will result in a temporary or permanent colostomy or ileostomy, you need to understand your scheme's stoma cover before surgery: - Is there a dedicated stoma/prosthetic benefit? - Is there a rand limit per year? - Which brands of stoma appliances are listed on the scheme formulary?
A stoma nurse at your hospital can advise on monthly consumable requirements. Typical monthly cost: R1,500–R3,500. If your scheme's limit is inadequate, a financial plan for out-of-pocket stoma costs is needed.
The Next Three Months: Checklist
| Action | Priority |
|---|---|
| Register with oncology case management | Immediate |
| Pre-authorise surgical procedure | Before surgery |
| Obtain written staging and biomarker test results | Within 2 weeks of diagnosis |
| Confirm oncology sub-limit | This week |
| Ask surgeon and anaesthesiologist for billing rates | Before surgery |
| Assess gap cover status and OPL (R220,000/year) | This week |
| Confirm oral chemo classification (oncology vs drug benefit) | If capecitabine is planned |
| Confirm stoma appliance coverage (if applicable) | Before discharge |
Support Resources
CANSA (Cancer Association of South Africa): 0800 22 6622 (toll-free) | www.cansa.org.za Colostomy Association of South Africa: www.colostomy.co.za Stoma support, patient communities, practical guidance
Talk to Eldon
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This page is general information about medical schemes. It is not medical advice: speak to a healthcare professional about your own treatment. Medical aid and gap cover advice is given by Eldon de Waal, a Supervised Representative of Approach Administration (FSP 23579).