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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
Salary Member Adult Child
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
Salary Member Adult Child
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
Salary Member Adult Child
R0-R8,595 R1,384 R979 R509
R8,596-R14,845 R1,532 R1,097 R570
R14,846+ R1,719 R1,223 R635
ONYX
Salary Member Adult Child
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
IN-HOSPITAL BENEFITS
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
OUT-OF-HOSPITAL BENEFITS
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
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 - 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 • 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•ServicemustbeprovidedbyDSP•PMBsoverrideallotherbenefitprovisions
PRESCRIBED MINIMUM BENEFITS (PMBs)100%ofSchemerate•ServicemustbeprovidedbyDSP•PMBsoverrideallotherbenefitprovisions
PRESCRIBED MINIMUM BENEFITS (PMBs)100%ofSchemerate•ServiceprovidedbyDSP•PMBsoverrideallotherbenefitprovision
PRESCRIBED MINIMUM BENEFITS (PMBs)100%ofSchemerate•ServiceprovidedbyDSP•PMBsoverrideallotherbenefitprovisions
IN-HOSPITAL BENEFITS
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
OUT-OF-HOSPITAL BENEFITS
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
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 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
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 • Limited to PMSA and Block benefit • Benefit is pro-rated from join date
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, 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
IN-HOSPITAL BENEFITS
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
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 • 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
Pathology • Unlimited
Physiotherapy • Subject to managed care rules • Limited to R3 389 per beneficiary per year
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
Surgical procedures (including maxillo-facial surgery) • Subject to managed care rules • Unlimited • 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 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
Emergency assistance (road and air) • Call 0800 44 4367 • Subject to use of emergency services DSP and managed care rules • Unlimited
HIV infection, AIDS and related illness • Managed care rules will apply
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
IN-HOSPITAL BENEFITS
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
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 • 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
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 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
Surgical procedures (including maxillo-facial surgery) • Subject to managed care rules • Unlimited • 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
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
Emergency assistance (road and air) • Call 0800 44 4367 • Subject to use of emergency services DSP and managed care rules • Unlimited
HIV infection, AIDS and related illness • Managed care rules will apply
Infertility • Subject to managed care rules and use of DSP
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: