Cancer and your medical aid

Cancer treatment is a Prescribed Minimum Benefit — an entry on a list in the regulations, which every scheme is obliged to pay for whatever plan you are on. Two things about that are worth knowing before you choose a plan, and neither is obvious from the words: which cancers are on the list, and what the entry obliges your scheme to pay for.

Not every cancer is a PMB

The law does not say “cancer is covered”. It says a treatable cancer is covered — and in Explanatory Note 3 to Annexure A it defines that word, for solid-organ cancers (breast, lung, prostate, colon and so on), quite narrowly. All three of these must hold — or, if they do not, the fourth must:

andthe cancer is confined to the organ it started in — it has not spread to organs next to it

andthere is no distant metastasis — it has not spread to a distant part of the body

andthere is no incurable damage to that organ, or to an organ you need to live

orif the three above do not hold — there is a well demonstrated five-year survival rate of more than 10% for the therapy being given, for that condition

Which means advanced cancer can fall outside the PMB entirely. A solid-organ cancer that has spread is generally not a “treatable cancer” in the legal sense, unless the fourth limb rescues it. It does not drop to a smaller must-pay benefit — the scheme’s obligation stops applying to it, and what you get is whatever your plan chose to offer on its own account.

This test does not reach the blood cancers. Note 3 applies to solid-organ malignant tumours and expressly excludes lymphomas; leukaemia and myeloma are not solid-organ tumours at all. So the staging test above is not what decides them.

What decides them, in practice, is the ordinary oncology benefit. We read the registered rules of the six schemes on this page and none of them names leukaemia, lymphoma or multiple myeloma separately — on these six there is no carve-out, better or worse. They are funded from the same oncology limit as any other cancer. One scheme’s registered annexure puts it beyond doubt by naming haematologists inside the oncology benefit itself.

And “covered in full” does not mean unlimited

Where that obligation does apply, a scheme must pay for your diagnosis, treatment and care — but the benchmark is what you would receive in the state sector. In practice that means three conditions travel with it:

You use their doctor and their hospital. Schemes appoint Designated Service Providers. Go elsewhere and you pay a share, even for a PMB.
You use their medicine list. A formulary. Off it, you are paid at a reference price and cover the difference.
The treatment has to be approved first. See the next section.

So “unlimited” describes the rand amount. It does not describe the provider, the medicine list, or the approval — and those are three separate places a cost can arise.

And “treatment” is a defined word too

Most entries in Annexure A describe the treatment as “medical management” or “surgical management”. Explanatory Note 2 says that means prevailing public-hospital practice for that condition — and then it takes seven things back out of it. Unless the entry for your condition names them, these are not included in generic management:

Tumour chemotherapy
Tumour radiotherapy
Bone marrow transplantation or rescue
Mechanical ventilation
Hyperbaric oxygen therapy
Organ transplantation
Anything not registered for use in South Africa

Read that first line again. Chemotherapy and radiotherapy are covered as a PMB for your cancer only where Annexure A explicitly names them for your cancer. This is the second reason “cancer is a PMB” is not the sentence people think it is.

Biologics and targeted therapy. The notes never mention them. If the drug is not registered in South Africa, the last line above settles it. If it is registered, it is still only a PMB where it falls inside the treatment your entry names — and in practice inside the scheme’s formulary and protocol. That makes a biologic a scheme benefit question, not a PMB question, which is why the answer differs so much between plans.

If a bone marrow transplant is on the table, Note 4 attaches three conditions to the PMB version: the patient is under 60; an allogeneic transplant needs an HLA-matched family donor; and the patient has not relapsed after a previous full course of chemotherapy. Chemotherapy funded as a PMB is a first full course — induction, consolidation and myeloablative components where indicated.

This is also the one place the schemes visibly diverge. Reading their registered rules: one names the transplant explicitly and funds it outside the oncology limit, so it does not consume the cover you need for everything else; three name it with limits of their own; and two do not name it at all, carrying only a general transplant line. If a transplant is a realistic part of your treatment, that difference is worth more than the headline limit.

You have to register, and treatment starts after approval

Every scheme runs an oncology programme, and none of them fund treatment simply because you have a diagnosis. The pattern is the same everywhere:

Your pathology results confirming the diagnosis go to the scheme.
Your oncologist submits a treatment plan — the specific drugs, the number of cycles, the radiotherapy.
The scheme's clinical team reviews it. Ask your scheme how long this takes; it is usually a matter of days, not weeks.
Funding starts from approval. Treatment you start before that is at your own risk.
Any change to the plan — a new drug, a further line of treatment — goes back for approval.

These steps are administrative, and they are where cost arises independently of how big the benefit is. A missed registration, an off-network provider, or a drug outside the approved plan each has a cost of its own. All three are avoidable, and easier to stay on top of with somebody doing it for you.

What the six schemes actually do

153plans compared

68offer nothing beyond the PMB minimum

4.6×spread between the lowest and highest limit

Scheme	Plans	PMB-only	Limit range	How the limit is shared
Profmed	11	0	R418,000–R773,000	per person
Discovery	35	15	R250,000–R500,000	per person, rolling 12 months — a threshold, not a cap
Fedhealth	32	11	R250,000–R643,340	per family; one plan has no limit
Momentum	38	18	R200,000–R500,000	per person; one plan has no limit
Bonitas	19	9	R168,100–R448,200	per family
Bestmed	18	15	no rand limit — set by protocol	—

“Per family” is not a detail. On Fedhealth and Bonitas the oncology limit is shared across everyone on the plan. One household, two diagnoses, one limit. On Discovery, Momentum and Profmed each person has their own.

“No rand limit” is not the same as unlimited. Bestmed states no rand figure for oncology on any plan. What limits it instead is the treatment protocol: oncology is funded at PMB level of care through its oncology network, ICON, and no biologic or high-cost medicine is funded beyond that level — except on Pace2, Pace3 and Pace4, which add a separate biologicals limit of R210,208 to R622,628.

Two plans set no overall oncology limit: Fedhealth maxima PLUS, through ICON on its Enhanced protocols, and Momentum Summit, through SAOC. “No limit” still comes with the same conditions as everywhere else: the scheme’s providers, its protocols, its approval — and a separate, smaller allowance for specialised and biological medicines. Go outside their providers and you pay a share.

The three costs the headline limit hides

1 · What happens after the limit

Treatment does not stop — your share of it starts. Momentum applies a 20% co-payment on approved treatment once the limit is reached, and Bonitas does the same on seven of its plans. Discovery’s figure is a threshold rather than a cap: past it, Discovery pays 80% of its own rate, with no overall limit, for the rest of the 12-month cycle. PMB-level treatment continues to be paid in full at a network provider, which brings you straight back to whether your cancer still meets the treatable test.

2 · Going outside their network

Bonitas applies a 30% co-payment where oncology is not obtained through its designated provider. Fedhealth applies 25%. On a R400,000 course of treatment, choosing your own oncologist is a six-figure decision.

3 · A smaller bucket inside the big one

Several plans set a separate, lower limit for specialised and high-cost medicines — the newer targeted and biological therapies — inside the overall oncology limit. Bonitas states R164,100 on some plans and R448,200 on others. Fedhealth states R200,630 and R402,500 depending on the plan. Momentum sets aside R200,000 for specialised oncology inside the overall limit on nineteen plans. On Bestmed, the biologicals limit above is the only route to these medicines.

So: are biologics covered? Generally yes — they sit inside the oncology benefit alongside chemotherapy and hormonal therapy. But the newest and most expensive ones are frequently carved into their own smaller limit or their own lower percentage, and they need separate approval. That carve-out, not the headline limit, is what decides whether a modern treatment is affordable.

Where gap cover fits — and where it does not

Gap cover exists for exactly the shortfalls above. Of the 35 gap products we track for 2026, 25 include an oncology benefit. Two things matter and neither is obvious from a brochure:

A first-diagnosis cash payment — a lump sum on diagnosis, to spend as you choose. Ambledown pays R50,000 on three of its products. Stratum pays R15,000 to R30,000 on two. Turnberry, Sirago and Zestlife pay between R8,000 and R40,000, scaled by the stage of the cancer at diagnosis.
An oncology co-payment benefit — which pays the shortfall when your scheme's limit runs out. Stratum states sub-limits of R50,000 to R60,000, and Discovery’s own gap cover R35,000 to R110,000. Several products carry the rider with no stated sub-limit.

Read the exclusions before you rely on the lump sum. Ambledown and Stratum pay on invasive cancer only, and exclude carcinoma in situ, pre-malignant conditions, all skin cancers except melanoma, and Stage 1 breast and prostate cancer. Several products stop the first-diagnosis benefit at age 65 — the years when you are most likely to need it.

Stage decides three separate things, then: whether the PMB obligation applies at all, how much a staged gap benefit pays, and on some products whether it pays anything.

If you are already being treated

Switching schemes mid-treatment is rarely straightforward and sometimes a bad idea. A cancer you already have is a condition you already have, which means a new scheme may apply a waiting period of up to twelve months to it. Before anyone talks to you about moving, get these answered in writing:

What to ask your scheme

Is my cancer being funded as a PMB, or from the plan's oncology benefit? Ask for the reason in writing.
How much of my annual limit is used, and when does the cycle restart?
Is my limit mine, or shared with my family?
Is my oncologist a designated provider? Is my pharmacy?
Are all my medicines on the formulary, and is any of them being paid at a reference price?
If my treatment plan changes, what has to be re-approved?

How we help

We cannot tell you whether your particular cancer meets the legal test — that is a determination for your scheme and your treating oncologist, and it turns on clinical facts we do not have. Anyone who tells you otherwise on a website is guessing with your treatment.

What we can do is the work around it. If you have us look after your medical aid — which costs you nothing extra, because your contribution is the same whether you use an advisor or not — the service covers:

registering you on the oncology programme, and resubmitting the treatment plan when it changes;
checking your oncologist, hospital and pharmacy against the designated network before you commit;
finding out from the scheme how much of your limit is used, whenever you ask and before a new treatment plan goes in;
putting together and submitting an appeal when a benefit is declined;
reading your gap cover and telling you what it will and will not pay.

Having an advisor does not change your contribution. Schemes charge the same contribution whether or not you use an advisor, and pay the advisor’s fee out of it. Regulation caps that fee at a small percentage of your contribution, up to a fixed monthly maximum — so it cannot grow with a richer plan beyond that ceiling, and it is disclosed to you before you sign anything.

About these figures. Plan figures are drawn from our own plan catalogue (version v154, signed 30 September 2026), covering 153 plans across six open schemes and 35 gap products for 2026. Scheme rules change annually and mid-year. Nothing on this page is advice about your situation; it is general information about how medical schemes fund cancer treatment.

AURA is a service of Silverhurst Wealth Partners. Advice on medical scheme membership and gap cover is given by Eldon de Waal as a supervised representative of Approach Administration (Pty) Ltd, FSP 23579. Silverhurst Wealth Partners (Pty) Ltd is an authorised financial services provider, FSP 53208.