Wednesday, 27 November 2018 

Funding for specialised cancer medicine approved through urgent Ex Gratia process 

After reviewing the previous funding decision as agreed, the Government Employees Medical Scheme (GEMS) was able to inform our member, Dr Bvuma, that his request for funding of the specialised cancer drug has been approved through an urgent Ex Gratia process. 

“The initial position of the Scheme not to fund this particular medicine was based on the fact that it is not registered in South Africa as treatment option for the specific type of cancer that the member requires treatment for,” says Dr Stan Moloabi, Chief Operations Officer of GEMS. 

“On review of the funding decision, a panel of independent oncology experts recommended that this specific treatment, although not registered locally for this indication at this stage, can potentially benefit the member.

“The fact that funding for the treatment was initially declined demonstrates how complex and sensitive it is to deal with funding healthcare needs of our members, particularly when newer drugs are involved. The Scheme has now shared the decision with our member that the requested treatment will be paid through Ex Gratia.”

It is on the basis of the review by the panel of independent oncology experts that Dr Bvuma’s treatment could be funded on an Ex Gratia basis.

“The Scheme has funded several treatment modalities for our member since his diagnosis in 2016 and acknowledges that there have been challenges that relate to funding of the current treatment requested. We are committed to funding the healthcare needs of our members in accordance with clinical need, the Scheme rules, cost-effectiveness and appropriateness,” he adds.

“As a healthcare funder, GEMS has a duty to exercise caution and circumspection with regard to treatment options that are not registered locally for a specific medical condition,” Dr Moloabi concludes.