BERYL Trust us to bring health within your reach20111212022944 PM) Marketing brochure 12...trust the Government Employees Medical Scheme (GEMS) to help support them in meeting their

GEMS aims to provide equal access to healthcare cover for all qualifying Public Service employees through affordable and comprehensive benefits. The interests of our members are protected at all times and we are committed to keeping to the highest corporate governance standards.

In the past six years, GEMS has proven itself to be a leader in the medical scheme industry and it is not hard to see why:•Ourbenefitplansareonaveragebetween10%and25%lesscostlythanmostmedicalschemes.•Ourbenefitoptionsprovidethesameormorebenefitsthanmanyothermedicalschemes.

Good quality healthcare cover is one of the most important aspects of both your finances and your wellbeing. Over 590 000 Public Service employees trust the Government Employees MedicalScheme(GEMS)tohelpsupporttheminmeetingtheirhealthcareneeds.Takecontrolofyourhealthcare cover by joining GEMS now.

The focus of GEMS is

to provide members

with access to excellent

healthcare cover that is

affordable.

GEMS is growing

More and more Public Service employees join us every year because of the quality andaffordablehealthcarebenefitsweoffer.We now proudly provide healthcare cover to over 1.6 million lives.

And as we grow and go from strength to strength, our goal remains the same: WewanttomakesurethatallPublicServiceemployeeshaveaccesstoqualityhealthcare.

SAPPHIRE

Salary Member Adult Child

R0-R5,710 R556 R407 R235

R5,711-R8,010 R582 R432 R253

R8,011-R13,720 R621 R454 R270

R13,721+ R689 R539 R325

BERYL


R0-R5,710 R642 R591 R355

R5,711-R8,010 R698 R638 R389

R8,011-R13,720 R758 R702 R419

R13,721+ R912 R843 R509

RUBY


R0-R8,595 R1,276 R892 R488

R8,596-R14,845 R1,424 R992 R548

R14,846+ R1,584 R1,104 R604

Pleasenote:25%ofRubycontributionsgotowardsthepersonalmedicalsavingsaccount(PMSA)

EMERALD


R0-R8,595 R1,384 R979 R509

R8,596-R14,845 R1,532 R1,097 R570

R14,846+ R1,719 R1,223 R635

ONYX


R0-R8,595 R2,124 R1,509 R633

R8,596-R18,315 R2,212 R1,566 R686

R18,316+ R2,388 R1,706 R765

How much you pay each month

This table shows you how much members pay each month to GEMS.

Salary column: Thisreflectsmonthlysalaryamountbeforetaxorotherbenefitsarededucted.

Member column: Thiscolumnshowshowmuchtheprincipalmember,whoisthePublicServiceemployeeregisteredwithGEMS,hastopay.

Adult column: Thiscolumnshowshowmuchyouhavetopayforyouradultdependants.

Child column: Thiscolumnshowshowmuchyouhavetopayforachilddependant.GEMScoverschildrenuptotheageof21,unlessthechildismentallyorphysicallydisabledorisbelow28yearsofageandisafull-timestudentregisteredatarecognisededucationalinstitution.

The information above is a summary only. Please contact us on 0860 00 4367 or visit our website at www.gems.gov.za for a comprehensive list of dependants covered by GEMS.

NotethatGEMShasfivebenefitoptionstochoosefrom: Sapphire, Beryl, Ruby, Emerald and Onyx. The lowest level of benefits and the lowest level of cost is the Sapphire option. The highest level of benefits and the highest cost is the Onyx option.

Bringing health within your reach

Who can join?

You can join GEMS if you are employed in:• ANationalDepartmentlistedinSchedule1ofthePublicServiceAct;• AProvincialDepartmentlistedinSchedule2ofthePublicServiceAct;• AProvincialAdministrationlistedinSchedule2ofthePublicService

Act;organisationalcomponentslistedinSchedule3ofthePublicServiceAct;or

• AnyemployergroupapprovedbytheScheme.

You cannot join GEMS if you are employed by:• TheSouthAfricanDefenceForce;• TheNationalIntelligenceAgency;• TheSouthAfricanSecretService;or• Anydepartmentwheretheconditionsofservicedonotallowyouto

joinGEMS.

Please contact us at 0860 00 4367 if you are not sure if you can join GEMS.

Why join GEMS?Did you know:• ItcancostR348toseeyourdoctorandget

medicineforflu?• ItcostsR4300forasingledayinaprivate

hospital?• ItcancostanywherebetweenR17000and

R26000justtohaveababy?• Itcancostasalarylevel5employeeR1500

foraday’sstayinhospital?• AdayinintensivecarewillcostyouR8186?

GEMShassetupagreementswithprofessional healthcare service providers (for example, doctors, dentists, and pharmacists) toensurethattheychargeforservicesatGEMS-approvedrates.If you use these healthcare service providers, you will not have any out of pocket expenses and your medical benefits will last longer.

Do you need more information?• Send an SMS to 083 450 4367 with your

Persalnumberandwewillcallyouback.Ask

your employer for your Persal number if you

donotknowit.• Visit www.gems.gov.zaformoreinformation.

• Send an email to: [email protected].

• Call us on 0860 00 4367.

ThisbrochureisasummaryofwhatGEMSoffersandhowmuchitcosts.Forthefullinformation,pleaserefertotheRulesoftheSchemeonourWebsiteunder“Aboutus”.Ifthereisanydispute,theRulesoftheSchemewillapply.PleasecontactusifyouneedacopyoftheSchemeRulesorifyouhaveanyquestionsaboutGEMS.

Trustustobringhealth

within your reach2012

How to join GEMS!

When it comes to your contribution, the amount you pay depends on how much you earn, the size of your family and the optionyouchoose.As a member of GEMS you are part of a scheme that is genuinely concerned about and focused on your needs – we listen when our members speak!

•Excellent healthcare benefits at affordablerates.

•Absolute privacy-yourmedicalinformationisalwayskeptconfidential-evenfromyouremployer.

•Quickandefficientclaimspaymentsevery 14 days.

•Regularmember communication.•ACallCentrethatcanhelpyouinany

one of the official South African languages.

•Friendly and efficient customer service at our Call Centre and regionaloffices.Ourregionalofficesarefoundacrossthecountry.Contactusforyournearestoffice.

•Accesstoextensive medical care at public and private healthcare facilities.

•Disease Management Programmes (DMPs)tomanagethetreatment and costs of chronic and otherillnesses.Achronicdiseaseisa medical condition that is persistent orlong-lastingandhasanimpactonyourworkandlife,forexamplecancer,diabetes.

•Acourierpharmacytoensurethatyou receive your chronic medicine eachmonth.Wecallthispharmacya‘designated service provider’.

•AnHIV/AidsDMPthatgivesyouconfidential helpincoveringyourcostsandmanagingyourcondition.

•A24-hour emergency medical service that covers a wide area of SouthAfrica.

•Innovative healthcare services and programmes such as a maternityprogrammeandwellnessscreeningdaysatyourworkplace.Weareaddingmoreservicesandprogrammesregularlybecausewewanttomakeiteasyforyoutostayhealthy.

•WhenyoujoinGEMS,youarepartof a financially strong medical schemewitharapidlygrowingmembership.

GEMS aims to bring you the best possible healthcare benefits to suit your pocket.For2012wewereabletokeeptheincreaseincontributions(how much a member pays monthly) inlinewithmedicalinflation(therateatwhich prices for healthcare services and medicationarerising).Thereisabenefitoption perfect for your family’s healthcare needsandyourpocket.

These are the total monthly contributions. (A contribution is the moneyyoupayfortheGEMSbenefits.)

Insomecases,youmightqualifyforasubsidyfromyouremployer.Asubsidyisan amount your employer pays towards thecostofGEMS.Ifyouqualifyforasubsidy, the employer will pay a portion of the contribution each month and you willpaytherest.PleasespeaktoyourHRpractitionertofindoutifyouqualifyforthesubsidyfromyouremployer.

Points to note about the subsidy:•Theamountdependsonthesizeof

your family •Theemployerisonlyallowedto

payupto75%ofyourmonthlycontributions, up to a maximum of R2,760eachmonth.

•Ifyourincomeiswithinsalarylevels1to5andyouchoosetheSapphireoption,youcouldqualifyfora100%subsidy.

GEMS monthly contributions 2012

GEMS offers affordable benefits to all!

To become a member, follow these steps:

Step 1:Get an application form by:•downloadingonefromwww.gems.gov.za,•contactingtheCallCentreon0860004367,•talkingtoyourHRdepartmentor•requestingoneatyournearestGEMSRegionalOffice.

Step 2:Completetheform–makesurethatyoucompleteallthesectionsinfullandincludeallthedocumentsweaskfor(pleasereadthesectioninthisbrochurecalled‘Whichdocumentsdoyouneedtoincludewithyourapplication?’).

Step 3:Send us the completed form and documents by:Fax:0861004367Post:GEMS,PrivateBagX782,CapeTown,8000Email:[email protected]:HandinyourapplicationatanyGEMSRegionalOffice.Please contact us on 0860 00 4367 to find out where your nearest Regional Office is.

Whichdocumentsdoyouneedtoincludewithyourapplication?

To join GEMS, you must provide:•acompletedapplicationform•certifiedcopiesofcertaindocuments,suchasidentitydocuments,foryou

and your family members

For a full list of all the documents that may be required, please visit www.gems.gov.za or phone us on 0860 00 4367. We can process your application only after we have received all the necessary documents.

YoucanhaveyourdocumentscertifiedatanypolicestationoryournearestGEMSRegionalOffice.Togetadocumentcertified,youmustshowtheoriginalandagoodqualityphotocopy.

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IN-HOSPITAL BENEFITS

Annual overall hospital limit (public hospitals, GEMS-approved registered unattached theatres and day clinics) • Service provided by DSP • Chronic medicine provided by Chronic DSP • Limited to overall annual hospital limit of R148 334 per family per year • TTO limited to 7 days

Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Subject to referral by DSP GP and managed care rules

Alternatives to hospitalisation (hospice, sub-acute hospitals and private nursing, excludes frail care) • Subject to managed care rules • Subject to annual hospital limit and sub-limit of R14 833 per family per year

Blood transfusion • Subject to managed care rules

Dentistry (conservative, restorative) • Only applicable to beneficiaries either under the age of 8 years, with severe trauma or impacted third molars • Subject to managed care rules • Subject to annual hospital limit and out-of-hospital dentistry limit • Excludes osseo-integrated implants, all implant-related procedures, orthognatic surgery and specialised dentistry • Subject to use of day theatres and DSP hospitals

Emergency services (casualty department) • Subject to managed care rules • Admission subject to pre-authorisation

General practitioners (GPs) • Consultations and visits • Subject to annual hospital limit

Maternity benefits (public hospitals and designated private hospitals) • Subject to registration on the Maternity Programme • Includes midwife services • Subject to annual hospital limit • Elective caesarean may be subject to second opinion and managed care rules • Includes complications of pregnancy for mother and post-natal (after delivery) care

Medical technologists • Includes materials

Mental health • Subject to managed care rules

Oncology (chemo- and radiotherapy) • In and out-of-hospital • Includes medicine and materials • Subject to managed care rules, clinical guidelines used in public facilities and MPL

Organ and tissue transplants • Subject to clinical guidelines used in public facilities • Includes materials

Pathology • Subject to managed care rules • Subject to annual hospital limit

Physiotherapy • Subject to managed care rules

Prosthesis • Subject to managed care rules • Subject to the annual hospital limit and a sub-limit of R16 946 per family per year • Bone cement paid from in-hospital benefits

Radiology (advanced) • Subject to managed care rules and list of approved services

Radiology (basic) • Subject to managed care rules • Subject to annual hospital limit • 2 x 2D ultrasound scans per pregnancy

Renal dialysis • Subject to managed care rules and clinical guidelines used in public facilities • In and out-of-hospital • Includes materials

Specialists • Consultations and visits • Subject to annual hospital limit

Surgical procedures (including maxillo-facial surgery) • Subject to annual hospital limit • Maxillo-facial surgery subject to annual sub-limit of R14 833 per family • Excludes osseo-integrated implants, all implant-related procedures and orthognatic surgery

OUT-OF-HOSPITAL BENEFITS

Alcohol and drug dependencies • Subject to managed care rules and use of DSP

Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Subject to referral by DSP GP • Subject to managed care rules

Audiology, occupational therapy and speech therapy • Subject to referral by DSP GP

Circumcision (to help prevent HIV infection) • Subject to managed care rules and use of DSP/GEMS Network provider • Global fee of R1 012, which includes all related costs of post-procedure care within month of procedure • Out of hospital benefit only

Dental services (conservative, restorative) • Subject to list of approved services, managed care rules and use of DSP - Conditions with pain and sepsis, fillings, clinically indicated dental services including extractions and emergency root canal procedure, intra-oral radiography • 1 event per beneficiary per year, subject to PMBs • Emergency out-of-Network visits limited to 1 event per beneficiary per year- Dentures (plastic) • Unlimited at DSP - Examinations and preventative treatment • 1 treatment episode per beneficiary per year- Specialised dentistry and other dentures

Emergency assistance (road and air) • Call 0800 44 4367 • Subject to use of emergency services DSP and managed care rules • Unlimited

General practitioners (GPs) • Consultations, visits and all other services at DSP/GEMS Network providers • Subject to managed care rules • Unlimited - Emergency medical conditions at DSP and involuntary use of non-DSP provider • Unlimited for PMBs - Voluntary use of out-of-Network providers • Member to pay the claim and submit proof of payment with the claim • 80% of Scheme rate (20% member co-payment) • Limited to 1 visit per beneficiary, 2 per family per year and R734 per event

HIV infection, AIDS and related illness • Managed care rules will apply

Infertility • Subject to managed care rules and use of DSP

Maternity (ante-natal and post-natal specialist visits) • Subject to registration on the Maternity Programme, referral from DSP GP and managed care rules• Includes 2 x 2D ultrasound scans per pregnancy • 5 doctor visits per pregnancy

Medical and surgical appliances and prothesis • Includes hearing aids, wheelchairs, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment and external prosthesis • In- and out-of-hospital • Subject to prescription by DSP GP and managed care rules • Limited to R4 448 per family

Mental health • Subject to managed care rules and the use of DSP • PAR

Optical services (Eye examinations, frames, lenses and acute medication) • Subject to use of DSP and approved list of frames • Limit of R3 058 per family every second year • Limited to 1 eye examination, 1 frame and a pair of lenses every second year per beneficiary • Acute medicine is subject to medicine formulary and must be prescribed by DSP • Benefit not pro-rated • Post cataract surgery, PMB benefit provides up to the cost of bifocal lens not more than R798 for both lens and frame, with a sub-limit of R158 for the frame

Pathology • Subject to referral by DSP GP and list of approved tests • Test required by specialists subject to referral by GP • Unlimited

Physiotherapy • Subject to referral by DSP GP

Prescribed medication and injection material • Prescribed and administered by a professional legally entitled to do so • Subject to MPL and MEL - Acute medical conditions • Subject to managed care rules, formulary and prescription by DSP • Unlimited at DSP • 30% co-payment on voluntary use of out-of-formulary medication or use of non-DSP pharmacy- Chronic medical conditions • Limited to CDL and DTP PMB chronic conditions • Subject to prior application and approval, the formulary, use of Chronic DSP as well as managed care rules • Unlimited at DSP • 30% co-payment on voluntary use of out-of-formulary medication or use of non-DSP pharmacy- Self-medication (OTC) • To be obtained from DSP for minor ailments • Subject to managed care rules and formulary • Limited to R44 per event, 5 events and R222 per family per year

Radiology (advanced) • Subject to managed care rules

Radiology (basic) • Subject to referral by DSP GP and list of approved services • 2 x 2D ultrasound scans per pregnancy provided for by maternity benefit • Unlimited

Specialists • Consultations, visits and all other services • Subject to DSP GP referral and managed care rules • Subject to PMBs • Ante-natal visits limited to 5 visits per pregnancy • 2 x 2D ultrasound scans per pregnancy


Annual overall hospital limit • Public hospitals, GEMS-approved private hospitals, registered unattached theatres and day clinics • Service provided by DSP • Chronic medicine provided by Chronic DSP • Subject to overall annual hospital limit of R741 682 per family per year • High care and ICU limited to 10 days per admission • TTO limited to 7 days

Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Subject to referral by DSP GP, managed care rules and registration with relevant statutory bodies • Annual limit of R1 479 per beneficiary and R2 224 per family

Alternatives to hospitalisation (hospice, sub-acute hospitals and private nursing) • Subject to managed care rules • Subject to annual hospital limit and sub-limit of R14 833 per family per year

Blood transfusion • Subject to annual hospital limit and sub-limit of R14 833 per family per year

Dentistry (conservative, restorative and specialised) • Only applicable to beneficiaries either under the age of 8 years, with severe trauma or impacted third molars • Subject to list of approved services and use of day theatres and DSP hospitals • Subject to annual hospital limit and out-of-hospital dentistry limit • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery

Emergency services (casualty department) • Subject to managed care rules • Admission subject to pre-authorisation

General practitioners (GPs) • Consultations and visits • Subject to annual hospital limit

Maternity benefits • Subject to registration on the Maternity Programme and managed care rules • Includes hospital, home birth and accredited birthing unit • Includes midwife services • Subject to annual hospital limit • Home birth/birthing unit subject to sub-limit of R7 351 per event • Includes complications for mother and newborn• Elective caesarean may be subjected to second opinion and managed care rules and processes

Medical technologist • Subject to annual hospital limit and sub-limit of R14 833 per family per year

Mental health • Subject to managed care rules • Subject to annual hospital limit and out-of-hospital sub-limit of R6 738 per family per year

Oncology (chemo- and radiotherapy) • In and out-of-hospital • Includes medicine and materials • Subject to managed care rules • Subject to annual hospital limit and sub-limit of R148 334 per family per year • Subject to MPL • Unlimited for PMBs

Organ and tissue transplants • Subject to clinical guidelines used in public facilities • Includes materials

Pathology • Subject to managed care rules • Subject to annual hospital limit

Physiotherapy • Subject to managed care rules • Subject to annual hospital limit

Prosthesis • Subject to managed care rules • Subject to annual hospital limit and a sub-limit of R22 251 per family per year • Unlimited for PMBs • Bone cement paid from in-hospital benefits

Radiology (advanced) • Subject to managed care rules and list of approved services • Shared with out-of-hospital advanced radiology limit of R22 251 per family per year

Radiology (basic) Subject to managed care rules • Includes 2 x 2D ultrasound scans per pregnancy • Subject to annual hospital limit

Renal dialysis • Subject to managed care rules and clinical guidelines used in public facilities programme • In and out-of-hospital • Includes materials • Subject to annual hospital limit and sub-limit of R148 334 per family per year • Unlimited for PMBs

Specialists • Consultations and visits • Subject to annual hospital limit

Surgical procedures • Subject to case management • Subject to annual hospital limit • Maxillo-facial surgery subject to annual sub-limit of R14 833 per family • Excludes osseo-integrated implants and orthognatic surgery


Alcohol and drug dependencies • Subject to managed care rules and use of DSP • PAR • 100% of Scheme rate • Limited to PMBs

Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Subject to referral by DSP GP, managed care rules and registration with relevant statutory bodies • Annual limit or R1 479 per beneficiary and R2 224 per family

Audiology, occupational therapy and speech therapy • Subject to referral by DSP GP • Included in allied health services benefit limit

Circumcision (to help prevent HIV infection) • Subject to managed care rules and use of DSP/GEMS Network provider • Global fee of R1 012, which includes all related costs of post-procedure care within month of procedure • Out-of-hospital benefit only

Dental services (including acute medicine) • Subject to list of approved services, managed care rules and use of DSP - Conditions with pain and sepsis, clinical indicated dental services including extraction and emergency root canal procedure, intra oral radiography • 1 event per beneficiary per year subject to PMBs- Dentures and specialised dentistry • Limit of R2 446 per beneficiary per year- Emergency non-DSP visit • Limited to 1 event per beneficiary per year- Examinations and preventative treatment • 1 consultation per beneficiary per year- Fillings • Unlimited at DSP


General practitioners (GPs) • Consultations, visits and all other services at DSP/GEMS Network providers • Subject to managed care rules • Unlimited - Emergency medical conditions at DSP and involuntary use of non-DSP provider • Unlimited - Voluntary use of out-of-Network providers • Member to pay the claim and submit proof of payment with the claim • 80% of Scheme rate (20% member co-payment) • Limited to 1 visit per beneficiary, 2 per family per year and R734 per event



Maternity • Ante-natal and post-natal specialist visits • Subject to registration on the Maternity Programme • Subject to referral from DSP GP • Includes 2 x 2D ultrasound scans per pregnancy • Part of specialists benefit

Medical and surgical appliances and prothesis • Includes hearing aids, wheelchairs, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment and external prosthesis • In and out-of-hospital • Subject to prescription by DSP GP and managed care rules • Limited to R7 417 per family per year

Mental Health (includes psychologists) • Subject to managed care rules and the use of DSP • Subject to annual hospital limit and combined with out-of-hospital sub-limit of R6 738 per family per year

Optical services • Eye examinations, frames, lenses and contact lenses (permanent and disposable) and acute medicine • Subject to use of DSP • Acute medicine subject to formulary • 1 examination per beneficiary per year • 1 frame and a pair of lenses, or 4 boxes of disposable contact lenses, or 1 set of permanent contact lenses • Limited to R1 035 per beneficiary every second year • Benefit is not pro-rated • Post cataract surgery, PMB benefit provides up to the cost of bifocal lens not more than R798 for both lens and frame, with a sub-limit of R158 for the frame

Pathology • Subject to referral by DSP GP and list of approved services • Test required by specialists subject to referral by GP • Unlimited

Physiotherapy • Subject to referral by DSP GP • Included in allied health services benefit limit

Prescribed medication and injection material • Prescribed and administered by a professional legally entitled to do so • Subject to MPL and MEL • Prescription by a specialist is only covered if referred by the DSP GP and the visit is pre-authorised- Acute medical conditions • Subject to managed care rules and formulary • Unlimited at DSP • Subject to prescription by DSP practitioner • 30% co-payment on voluntary use of out-of-formulary medication or use of non-DSP pharmacy - Chronic medical conditions • Limited to CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of Chronic DSP • Subject to prescription by DSP practitioner • No annual limit • 30% co-payment on voluntary use of out-of-formulary medication or use of non-DSP pharmacy - Self-medication (OTC) • Subject to managed care rules and formulary • Limited to R44 per event and 5 events and R222 per family per year • Subject to use of DSP

Radiology (advanced) • Subject to managed care rules • Shared with in-hospital advanced radiology limit of R22 251 per family per year

Radiology (basic) • Subject to referral by DSP GP and list of approved services • 2 x 2D ultrasound scans per pregnancy provided for by maternity benefit • Unlimited

Specialists • Consultations and visits • Subject to DSP GP referral, managed care rules and list of approved services for radiology and pathology • Limited to 5 consultations or R2 669 per family per year with a sublimit of 3 consultations or R1 779 per beneficiary per year

PRESCRIBED MINIMUM BENEFITS (PMBs)100%ofSchemerate•ServicemustbeprovidedbyDSP•PMBsoverrideallotherbenefitprovisions



PRESCRIBED MINIMUM BENEFITS (PMBs)100%ofSchemerate•ServiceprovidedbyDSP•PMBsoverrideallotherbenefitprovision

PRESCRIBED MINIMUM BENEFITS (PMBs)100%ofSchemerate•ServiceprovidedbyDSP•PMBsoverrideallotherbenefitprovisions


Annual hospital limit (Public and private hospitals, unattached theatres and day clinics) • Unlimited • R11 965 per beneficiary annual limit for non-PMB, 1 day admissions (day-case) • Not pro-rated

Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Subject to managed care rules • Limited to PMSA and Block benefit • Medicines prescribed by allied health professionals

Alternatives to hospitalisation (hospice, sub-acute hospitals and private nursing) • Excludes frail care and recuperative holidays • Includes physical rehabilitation for approved conditions • Subject to managed care rules • Unlimited

Blood transfusion • Subject to managed care rules • Unlimited • Includes Erythropoietin (hormone that promotes formation of red blood cells)

Dentistry (conservative, restorative and specialised) • Only applicable for beneficiaries either under the age of 8 years, with severe trauma or impacted third molars • Subject to list of approved services and use of day theatres • General anaesthesia and conscious sedation subject to managed care rules • Professional fees subject to shared limit with out-of-hospital dentistry benefit of R2 280 per beneficiary per year • Excludes osseo-integrated implants, all implant-related procedures and orthognatic surgery

Emergency services (casualty department) • Subject to managed care rules a • Admission subject to pre-authorisation • Will be paid from out-of-hospital GP benefit if pre-authorisation is not obtained

General practitioners (GPs) • Consultations and visits • Unlimited

Maternity benefits (including midwife) • Subject to registration on the Maternity Programme and managed care rules • Includes hospital, home birth and registered birthing unit • Hospital birth unlimited • Home birth or birthing unit limited to R7 351 per beneficiary per year • Elective caesarean may be subject to second opinion and managed care rules

Medical technologist • Subject to case management • Unlimited

Mental health • Accommodation, theatre fees, medicine, professional fees from GPs, psychiatrists, psychologists and registered counselors • Subject to managed care rules • Limited to R12 565 per family per year for non-PMBs • Maximum of 3 days hospitalisation by GP

Oncology (chemo- and radiotherapy) • In and out-of-hospital • Includes medicine and materials • Subject to managed care rules • Limit of R226 182 per family per year • Sub-limit of R170 963 per family per year for biological and similar specialised medicines • Includes cost of pathology, radiology, medical technologist and oncology medicine • Subject to MPL

Organ and tissue transplants • Subject to clinical guidelines used in public facilities • Includes materials • Limited to R418 849 per beneficiary per year • Limit includes all costs associated with transplant, including immuno-suppressants • Organ harvesting limited to RSA

Pathology • Unlimited

Physiotherapy • Subject to managed care rules • Limited to R3 389 per beneficiary per year

Prosthesis • Subject to managed care rules • Shared with medical and surgical appliances as well as out-of-hospital prosthesis limit of R28 500 per family per year • Bone cement paid from in-hospital benefit

Radiology (advanced) • Subject to managed care rules • Specific authorisation (in addition to hospital pre-authorisation) required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies • Shared with out-of-hospital advanced radiology limit of R15 078 per family per year

Radiology (basic) • Unlimited

Renal dialysis • Subject to managed care rules and clinical guidelines used in public facilities • In and out-of-hospital • Includes materials • Limited to R179 503 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Includes cost of pathology, radiology, medical technologists and immuno-suppressants

Specialist Services • Consultations and visits • Unlimited

Surgical procedures (including maxillo-facial surgery) • Subject to managed care rules • Unlimited • Excludes osseo-integrated implants, all implant-related procedures and orthognatic surgery


Personal medical savings account (PMSA) • Excludes PMB claims • 25% of contribution • Benefits pro-rated from join date

Block benefit • Claims paid against this benefit once PMSA limit is reached • Limited to R1 190 per family per year • Benefit is pro-rated from join date


Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Subject to managed care rules and registration with relevant statutory bodies • Limited to PMSA and Block benefit • Medicine prescribed by allied health professionals

Audiology, occupational therapy and speech therapy • Limited to PMSA and Block benefit

Circumcision (to help prevent HIV infection) • Subject to managed care rules and use of DSP/GEMS Network provider • Global fee of R1 012, which includes all related costs of post-procedure care within month of procedure •Out of hospital benefit only

Contraceptives (oral, insertables, injectables and dermal) • Subject to managed care rules • Subject to PMSA

Dental services (conservative and restorative dentistry - includes plasticdentures, and special dentistry - includes metal base partial dentures) • General anaesthesia and conscious sedation require preauthorisation and are subject to managed care rules (Only applicable to beneficiaries either under the age of 8 years, with severe trauma or impacted third molars) • Shared with in-hospital dentistry limit of R2 280 per beneficiary per year • No pre-authorisation for metal base partial dentures • Excludes osseo-integrated implants, all implant-related procedures and orthognatic surgery


General practitioners (GPs) • Consultations, visits and all other services • Limited to PMSA and Block benefit • Benefit is pro-rated from join date



Maternity • Ante-natal and post-natal specialist visits • Subject to registration on the Maternity Programme, managed care rules and PMBs • Subject to PMSA • Includes 2 x 2D ultrasound scans per pregnancy

Medical and surgical appliances and prosthesis • Includes hearing aids, wheelchairs, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment and external prothesis • In and out-of-hospital • Subject to managed care rules • Shared limit with in-hospital prosthesis of R28 500 per family per year • Sub-limit of R11 120 per family per year • Diabetic accessories, with the exception of glucometers, paid from chronic medication benefit

Mental health • Consultations, assessments, treatments and counselling by GPs, psychiatrists, psychologists, psychometrists or registered counsellors • Subject to managed care rules • Limited to PMSA • If offered as alternative to hospitalisation, then hospital benefits will apply

Optical services • Frames, lenses and contact lenses (permanent and disposable) • Refractive eye surgery • Eye examinations • Either spectacles or contact lenses (not both) can be claimed for in a benfit year • Limited to PMSA and Block benefit • Limited to 1 eye examination per beneficiary per year • Excludes variable tint and photochromic lenses • Benefit not prorated • Post cataract surgery, PMB benefit provides up to the cost of bifocal lens not more than R798 for both lens and frame, with a sub-limit of R158 for frame

Pathology • Subject to managed care rules • Limited to PMSA and Block benefit

Physiotherapy • Limited to PMSA and Block benefit

Prescribed medication and injection material • Prescribed and administered by a professional legally entitled to do so • Subject to MPL and MEL - Acute medical conditions • Subject to managed care rules and formulary • Subject to PMSA • 30% co-payment on voluntary use of out-of-formulary medication • Dispensing fee limited to 30% up to R30 per line item- Chronic medical conditions • CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of Chronic DSP • Unlimited for CDL and DTP PMB conditions • All other conditions subject to PMSA • 30% co-payment on voluntary use of out-of-formulary medication or use of non-DSP pharmacy- Prescribed medicine from hospital stay (TTO) • Subject to PMSA • TTO limited to 7 days- Self-medication (OTC) • Subject to managed care rules and formulary • Subject to PMSA

Preventative services • Serum cholesterol, bone density scan, pap smear, prostate specific antigen, glaucoma screening, serum glucose and mammogram • Limited to 1 of each service per beneficiary per year rolling over 3 years • Each test can only be done once over a three year period• Pap smears can be done annually

Radiology (advanced) • Subject to managed care rules • Specific authorisation required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies • Shared with in-hospital advanced radiology limit of R15 078 per family per year

Radiology (basic) • X-rays and soft tissue ultrasound scans • 2 x 2D ultrasound scans provided for by maternity benefit • Subject to PMSA

Specialists • Consultations, visits and all other services • Limited to PMSA and Block benefit • Benefit is pro-rated from join date


Annual in-hospital benefit • Public and private hospitals, unattached theatres and day clinics • Unlimited • R11 965 per beneficiary annual limit for non-PMB, 1 day admissions (day- case) • Not pro-rated

Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, physiotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Shared with out-of-hospital limit of R1 112 per family per year • includes medicines prescribed by allied health professionals


Blood transfusion • Includes Erythropoietin (hormone that promotes the formation of red blood cells) • Unlimited

Breast reduction • Subject to managed care rules • Unlimited

Dentistry (conservative, restorative and specialised) • Only applicable to beneficiaries either under the age of 8 years, with severe trauma or impacted third molars • General anaesthesia and conscious sedation require pre-authorisation and are subject to managed care rules and processes (Only applicable to beneficiaries either under the age of 8 years, with severe trauma or impacted third molars) • Subject to list of approved services and use of day theatres • Professional fees shared with out-of-hospital dentistry • Limited to R3 503 per beneficiary per year • Conservative and restorative dentistry not to exceed R1 668 per beneficiary per year • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery

Emergency services (casualty department) • Subject to managed care rules • Will be paid from out-of-hospital GP benefit if pre-authorisation is not obtained • Admission subject to pre-authorisation

General practitioners • Consultations and visits • Unlimited

Maternity benefits (including midwife) • Subject to registration on the Maternity Programme and managed care rules • Includes hospital, home birth and registered birthing unit • Hospital birth unlimited • Home birth limited to R7 351 per beneficiary per year • Elective caesarean may be subject to second opinion and managed care rules

Medical technologist • Subject to case management • Unlimited Mental health • Accommodation, theatre fees, medicine, professional fees from GPs, psychiatrists, psychologists and registered counsellors • Subject to managed care rules • Limited to R12 565 per family per year• Maximum of 3 days hospitalisation by GP

Oncology (chemo and radiotherapy) • In- and out-of-hospital • Includes medicine and materials • Subject to registration on managed care programme • Limited to R251 312 per family per year • Specialised medicine sub-limit of R170 963 per family per year • Includes cost of pathology, radiology, medical technologist and oncology medicine • Subject to MPL

Organ and tissue transplants • Subject to clinical guidelines used in public facilities • Includes materials • Limited to R418 849 per beneficiary per year • Limit includes all costs associated with transplant including immuno-suppressants • Organ harvesting limited to RSA



Prosthesis • Shared with medical and surgical appliances as well as out-of-hospital external prothesis limit of R28 500 per family per year • Bone cement paid from in-hospital benefits

Radiology (advanced) • Specific authorisation (in addition to hospital pre-authorisation) required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies • Subject to managed care rules • Shared with out-of-hospital advanced radiology • Limited to R15 078 per family per year

Radiology (basic) • Unlimited Renal dialysis • Subject to managed care rules and clinical guideline used in public facilities • In and out-of-hospital • Includes materials • Limited to R179 503 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Includes cost of pathology, radiology medical technologists and immuno-suppressants

Specialists • Consultations and visits




Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Subject to managed care rules and registration with relevant statutory bodies • Shared with in-hospital allied health services

limit of R1 112 per family per year • Includes medicine prescribed by allied health professionals

Auxiliary Block benefit • Audiology, occupational therapy and speech therapy as well as pathology and medical technology • Subject to managed care rules • Limited to R1 529 per beneficiary and R3 064 per family per year • Benefit is pro-rated from joining date - Audiology, occupational therapy and speech therapy • Occupational or speech therapy performed in-hospital will be paid from the in-hospital benefit • Sub-limit of R1 229 per beneficiary and R2 457 per family per year- Pathology and medical technology • Subject to managed care rules

Caregiver Block benefit • Out-of-hospital GP and specialist consultations and visits, maternity and physiotherapy • Limited to R3 136 per beneficiary and R6 271 per family per year • Benefit is pro-rated from join date - Maternity • Ante-natal and post-natal specialist visits • Subject to registration on the Maternity Programme and managed care rules • Includes 2 x 2D ultrasound scans per pregnancy- Physiotherapy • Subject to managed care rules • Physiotherapy performed in-hospital or instead of hospitalisation will be paid from in-hospital benefit • Sub-limit of R1 529 per beneficiary and R3 054 per family per year

Circumcision (to help prevent HIV infection) • Subject to managed care rules • Global fee of R1 012, which includes all related costs of post-procedure care within month of procedure • Out of hospital benefit only

Dental services (conservative and restorative dentistry - includes plastic dentures, and special dentistry - includes metal base partial dentures) • General anaesthesia and conscious sedation require pre-authorisation and are subject to managed care rules (Only applicable to beneficiaries either under the age of 8 years, with severe trauma or impacted third molars) • Shared with in--hospital dentistry limit of R3 503 per beneficiary per year • Conservative and restorative dentistry not to exceed R1 668 per beneficiary per year • Excludes osseo-integrated implants, all implant-related procedures and orthognatic surgery • No pre-authorisation required for metal base dentures



Infertility • Subject to managed care rules and processes and use of DSP

Medical and surgical appliances and external prothesis • Includes hearing aids, wheelchairs, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment and external prosthesis • In- and out-of-hospital • Subject to managed care rules and processes • Shared with in-hospital prothesis limit of R28 500 per family per year • Sub-limit of R11 120 for medical and surgical appliances per family per year • Diabetic accessories and appliances , except for glucometers to be claimed from the chronic medication benefit

Mental health • Consultations, assessments, treatments and/or counselling by GPs, psychiatrists, psychologists, psychometrists or registered counsellors • Subject to managed care rules • If offered as alternative to hospitalisation, then hospital benefits will apply • Shared with in-hospital mental health limit of R12 565 per family per year • Sub-limit of R3 726 for out-of-hospital psychologist consultations

Optical services • Frames, lenses and contact lenses (permanent and disposable) • Refractive eye surgery • Eye examinations • Subject to optical managed care programme • Either spectacles or contact lenses (not both) can be claimed for in a benefit year • Sub-limit of R1 668 per beneficiary every second year and annual limit of R3 336 per family • Frames not to exceed R1 032 • Limited to 1 eye examination per beneficiary per year • Excludes variable tint and photochromic lenses • Benefit not pro-rated • Post cataract surgery, PMB benefit provides up to the cost of bifocal lens and not more than R798 for both lens and frame, with a sub-limit of R158 for frame

Prescribed medication and injection material • Prescribed and administered by a professional legally entitled to do so • Subject to MPL and MEL - Acute medical conditions • Subject to managed care rules and formulary • Limit of R2 513 per beneficiary and R7 539 per family per year •30% co-payment on voluntary use of out-of-formulary medication • Dispensing fee limited to 30% up to R30 per line item- Chronic medical conditions • CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of chronic DSP • Limit of R7 539 per beneficiary and R15 179 per family per year • 30% co-payment on voluntary use of out-of-formulary medication or use of non-DSP pharmacy- Contraceptives • Subject to managed care rules, formulary and processes • Subject to acute medication benefit limit • Sub-limit of R1 906 per beneficiary per year- Prescribed medicine from hospital stay (TTO) • Included in acute medication benefit limit • TTO limited to 7 days- Self-medication (OTC) • Subject to managed care rules and formulary • Subject to acute medicine benefit limit and sub-limit of R818 per beneficiary per year

Radiology (advanced) • Subject to managed care rules • Specific authorisation required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies • Shared limit with in-hospital advanced radiology of R15 078 per family per year

Radiology (basic) • X-rays and soft tissue ultrasound scans • 2 x 2D ultrasound scans provided for by maternity benefit • Annual sub-limit of R2 502 per beneficiary and R4 587 per family per year


Annual in-hospital benefit • Public and private hospitals, unattached theatres and day clinics • Unlimited • R11 965 per beneficiary annual limit for non-PMB, 1 day admissions (day-case) • Not pro-rated

Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Subject to managed care rules • Subject to day-to-day Block benefit • Services performed in hospital or instead of hospitalisation will be paid from in-hospital benefit • Includes medicine prescribed by allied health professionals


Blood transfusion • Subject to managed care rules • Includes Erythropoietin (hormone that promotes the formation of red blood cells) • Unlimited

Breast reduction • Subject to managed care rules • Unlimited

Dentistry (conservative, restorative and specialised) • Only applicable to beneficiaries either under the age of 8 years, with severe trauma or impacted third molars • Subject to list of approved services and use of day theatres • General anaesthesia and conscious sedation also subject to managed care rules • Professional fees shared with out-of-hospital dentistry benefit limit of R5 804 per beneficiary per year • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery

Emergency services (casualty department) • Subject to managed care rules • Paid from day-to-day Block benefit if pre-authorisation is not obtained • Admission subject to pre-authorisation

General practitioners • Consultations and visits • Unlimited

Maternity benefits (including midwife) • Subject to registration on the Maternity Programme and managed care rules • Includes hospital, home birth and registered birthing unit • Hospital birth unlimited • Home birth limited to R7 351 per beneficiary per year • Elective caesarean may be subject to second opinion and managed care rules

Medical technologist • Subject to case management • Unlimited

Mental health • Accommodation, theatre fees, medicine, hospital equipment, professional fees from GPs, psychiatrists, psychologists and registered counsellors • Subject to managed care rules • Limited to R26 387 per family per year for• Maximum of 3 days hospitalisation by GP

Oncology (chemo- and radiotherapy) • In- and out-of-hospital • Includes medicine and materials • Subject to managed care rules • Limit of R329 849 per family per year • Sub-limit of R222 946 per family for biological and similar specialised medicines • Includes cost of pathology, radiology, medical technologist and oncology medicine • Subject to MPL

Organ and tissue transplants • Subject to clinical guidelines used in public facilities • Includes materials • Limited to R418 849 per beneficiary per year • Limit includes all costs associated with transplant, including immuno-suppressants • Organ harvesting limited to RSA



Prosthesis • Subject to managed care rules • Shared with medical and surgical appliances and prothesis benefit limit of R38 500 per family per year • Bone cement paid from in-hospital benefits

Radiology (advanced) • Subject to managed care rules • Shared with out-of-hospital advanced radiology limit of R18 848 per family per year • Specific authorisation (in addition to hospital pre-authorisation) required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies

Radiology (basic) • Unlimited

Renal dialysis • Subject to managed care rules and clinical guideline used in public facilities • In- and out-of-hospital • Includes materials • Limited to R179 503 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Includes cost of pathology, radiology medical technologists and immuno-suppressants

Specialists • Consultations and visits • Unlimited




Circumcision (to help prevent HIV infection) • Subject to managed care rules • Global fee of R1 012, which includes all related costs of post-procedure care within month of procedure • Out of hospital benefit only

Day-to-day Block benefit • Includes GP and specialist services, basic radiology, pathology, allied health services, physiotherapy, occupational therapy and speech therapy, mental health, maternity and contraceptives • Subject to managed care rules • Limited to R6 594 per beneficiary and R13 188 per family per year • Benefit is pro-rated from joining date - Allied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • If offered as alternative to hospitalisation, then hospital benefits will apply - Contraceptives • Subject to the formulary • Sub-limit of R2 391 per family per year- Maternity • Ante-natal and post-natal specialist visits • Subject to registration on the Maternity Programme • Includes 2 x 2D ultrasound scans per pregnancy- Mental health • Consultations, assessments, treatments and/or counselling by GPs, psychiatrists, psychologists, psychometrists or registered counsellors • If offered as alternative to hospitalisation, then hospital benefits will apply, subject to pre-authorisation and managed care rules - Physiotherapy, occupational therapy and speech therapy • If offered in hospital or instead of hospitalisation will be paid from in-hospital benefits, subject to pre-authorisation - Pathology • PAR • 100% Scheme rate •Subject to managed care rules - Radiology (basic) • X-rays and soft tissue scans • 2 x 2D ultrasound scans per pregnancy provided for by maternity benefit

Dental services (conservative and restorative dentistry - includes plastic dentures, and special dentistry - includes metal base partial dentures) • General anaesthesia and conscious sedation subject to pre-authorisation (Only applicable to beneficiaries either under the age of 8 years, with severe trauma or impacted third molars) • Subject to managed care rules • Shared limit with in-hospital dentistry of R5 804 per beneficiary per year • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery • No pre-authorisation for metal base dentures




Medical and surgical appliances and prothesis • Includes hearing aids, wheelchairs, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment and external prothesis • In- and out-of-hospital • Subject to managed care rules • Shared with in-hospital prosthesis limit of R38 500 per family per year • Sub-limit of R12 871 for medical and surgical appliances per family per year

Optical services • Frames, lenses and contact lenses (hard and disposable) • Refractive eye surgery • Eye examinations • Subject to optical managed care programme • Overall limit of R1 969 per beneficiary every second year and an annual limit of R3 948 per family • Sub-limit of R1 668 per frame • Either spectacles or contact lenses (not both) can be claimed for in a benefit year • Limited to 1 eye examination per beneficiary per year • Excludes variable tint and photochromic lenses • Benefit is not pro-rated • Post cataract surgery, PMB benefit provides up to the cost of bifocal lens and not more than R798 for both lens and frame, with a sub-limit of R158 for frames

Prescribed medication and injection material • Prescribed and administered by a professional legally entitled to do so• Subject to MPL and MEL - Acute medical conditions • Subject to managed care rules and formulary • Limit of R4 237 per beneficiary and R11 865 per family per year • 30% co-payment on voluntary use of out-of-formulary medication • Dispensing fee limited to 30% up to R30 per line item- Chronic medical conditions • CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of chronic DSP • Limit of R12 872 per beneficiary and R26 387 per family per year • 30% co-payment on voluntary use of out-of-formulary medication or use of non-DSP pharmacy- Prescribed medicine from hospital stay (TTO) • included in acute medication benefit limit • TTO limited to 7 days- Self-medication (OTC) • Subject to managed care rules and formulary • Subject to acute medicine benefit limit and sub-limit of R1 279 per family per year

Radiology (advanced) • Subject to managed care rules • Specific authorisation required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies • Shared limit with in-hospital advanced radiology of R18 848 per family per year

GLOSSARY

ACDL: Additional chronic disease list.AlistofchronicdiseasestheScheme covers in addition to the CDL.

Benefit option: EachofthefiveGEMSbenefitoptions–namelySapphire, Beryl, Ruby, Emerald and Onyx – have different cost and will each provide you with its ownrangeofhealthcarebenefits.

Benefit schedule: Alistingofthebenefitsprovidedforbyeachbenefitoption.

CDL: Chronicdiseaselist.Alistofthe26specificchronicdiseaseswe need to provide a minimum levelofcoverfor,asstatedbylaw.

CT and MRI scans: Special x-raystakenoftheinsideofyourbodytotrytofindthecauseofamedicalcondition.

DMP: DiseaseManagementProgramme.Specificcareprogrammestohelpmembersmanagevariouschronicdiseasesandconditions.

DSP: Designatedserviceprovider.A healthcare service provider the Schemehasanagreementwithtoprovidespecificservicestomembersatspecificprices.

DTP: TheDiagnosisandTreatmentPairsisalistofthe270PMBs in the Medical Schemes Actlinkedtothebroadtreatmentforspecificconditions.

MEL: Medicineexclusionlist.Alist of medicines that GEMS does notcover.

MPL: Medicinepricelist.Areferenceweusetoworkoutthepricesofgroupsofmedicines.

PAR: Pre-authorisationisneeded.TheprocessofinformingGEMSof a planned procedure before theevent.GEMSwillthenassess whether we will cover the procedure.Pre-authorisationmustbeobtainedatleast48hoursbeforetheevent.Inemergencycases authorisation must be obtainedwithinoneworkingdayaftertheevent.

PDF: Professionaldispensingfee.A maximum fee that a pharmacist ordispensingdoctormaychargefor their services, as set out in SouthAfricanlaw.

PMSA: Personalmedicalsavingsaccount.Theportionofyourmonthly contribution allocated to asavingsaccountheldinyourname.Thisaccountistopayforyourout-of-hospitalmedicalexpenses. PMBs: Prescribed minimum benefits.BasicbenefitsthatGEMS provides for certain medicalconditions.GEMS,likeallother medical schemes in South Africa,mustofferthesebenefitsaccordingtothelaw.

Scheme rate: Thepriceagreedby the Scheme for the payment of healthcare services provided by service providers to members of theScheme.

SEP: Singleexitprice.Theone price that a medicine manufacturerorimporterchargesformedicinetoallitscustomers.ThispriceissetoutinSouthAfricanlaw.

TTO: Treatmenttakenout.Themedication you receive when beingdischargedfromhospital.Usuallylastfor7days.

SAPPHIRE BERYL RUBY EMERALD ONYX

Pre-authorisation is needed

100% of Scheme rate

Limited to PMBs

Key:

Documents

BERYL Trust us to bring health within your reach20111212022944 PM) Marketing brochure 12...trust the Government Employees Medical Scheme (GEMS) to help support them in meeting their