Prescribed minimum benefits (PMBs)100% of Scheme rate • Service must be provided by a DSPPMBs override all other benefit limitations

Please refer to the glossary (word list) at the end for an explanation of the terms and abbreviations.

Pre-authorisation is needed100% of Scheme rate

Limited to PMBsSubject to managed care rules

What’s new in 2013?1. A5.5%increaseinbenefitlimits.2. Asub-limitofR15000underorganandtissuetransplantsforlocalandimportedcornealgrafts.3. Thereisnowanin-hospitaldentistryinclusionoflingualandlabialfrenectomiesundergeneral anaesthesiaforchildrenundertheageofeight.4. Out-of-hospitaltreatmentofbony,impactedthirdmolarsunderconscioussedationwillbe coveredat200%oftheSchemerate.5. Post-surgicalhomenursingcareasanalternativetohospitalisationisnowcovered.6. Preventativecareservices,suchaspapsmearsandotherstandardscreenings,willnowbecovered,subjecttothe managedcarerulesoftheScheme.7. TheDay-to-dayBlockBenefitincludestheGPNetworkExtenderBenefitforbeneficiariesregisteredontheChronic MedicineProgramme.8. Alzheimer’shasbeenaddedtotheACDL.

Bringing health within your reach

Emerald is the traditional option designed to offer comprehensive cover which offers access to care at the provider of your choice, subject to benefits and Scheme rules.

Read all about your benefits and find answers to your most frequently asked questions in this easy to read, pocket size mini-guide that you can refer to - anytime, anywhere!

IN-HOSPITAL BENEFITS

Annual in-hospital benefit • Public and private hospitals, registered unattached theatres and day clinics • Accommodation in private ward subject to motivation by attending practitioner and managed care rules • Unlimited • R12 623 per beneficiary annual limit for non-PMB, 1 day admissions, not pro-ratedAllied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Shared with out-of-hospital limit of R1 173 per family per year • Includes medicines prescribed by allied health professionalsAlternatives to hospitalisation (hospice, sub-acute hospitals and private nursing) • Excludes frail care and recuperative holidays • Includes physical rehabilitation for approved conditions and post-surgical home nursing care • UnlimitedBlood transfusion • Includes Erythropoietin (hormone that promotes the formation of red blood cells) • UnlimitedBreast reduction • UnlimitedDentistry (conservative, restorative and specialised)• General anaesthesia and conscious sedation subject to managed care rules • Only applicable to beneficiaries under the age of 8 years, with severe trauma or impacted third molars• Lingual and labial frenectomies under general anaesthesia for children under the age of 8 subject to managed healthcare programme • Subject to list of approved services and use of day theatres • Shared with out-of-hospital dentistry• Limited to R3 696 per beneficiary per year • Conservative and restorative dentistry not to exceed R1 760 per beneficiary per year • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery Emergency services (casualty department) • Will be paid from out-of-hospital GP Services if pre-authorisation is not obtained• Admission subject to pre-authorisationGeneral practitioners (GPs) • Consultations and visits • Unlimited

Maternity benefits (including midwife) • Subject to registration on the Maternity Programme • Includes hospital, home birth and registered birthing unit • Hospital birth unlimited, includes complications for mother and newborn • Home birth limited to R7 755 per beneficiary per year • Elective caesarean may be subject to second opinionMedical technologist • Subject to case management • Unlimited

Mental health • Accommodation, theatre fees, medicine, professional fees from GPs, psychiatrists, psychologists and registered counsellors • Limited to R13 256 per family per year for non-PMBs • Maximum of 3 days hospitalisation by GPOncology (chemo and radiotherapy) • In- and out-of-hospital • Includes medicine and materials • Subject to registration on managed care programme • Limited to R265 134 per family per year • Specialised medicine sub-limit of R180 366 per family per year • Includes cost of pathology, radiology, medical technologist and oncology medicine • Subject to MPLOrgan and tissue transplants • Subject to clinical guidelines used in public facilities • Includes materials • Limited to R441 886 per beneficiary per year • Sub-limit of R15 000 per beneficiary per year for corneal grafts, subject to managed care rules • Limit includes all costs associated with transplant including immuno-suppressants, subject to PMBs • Organ harvesting limited to RSA, except for cornea tissuePathology • Unlimited Physiotherapy • Limited to R3 575 per beneficiary per year

Prostheses • Includes prostheses and surgically implanted internal devices, including all temporary prostheses and all temporary or permanent devices used to assist with delivery of internal prostheses • Shared with medical and surgical appliances as well as out-of-hospital external prostheses limit of R30 068 per family per year • Scheme may arrange supply of prostheses • Bone cement paid from in-hospital benefitsRadiology (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 • Shared with out-of-hospital advanced radiology • Limited to R15 907 per family per yearRadiology (basic) • Unlimited Renal dialysis • Subject to clinical guideline used in public facilities • In- and out-of-hospital • Includes materials • Includes related pathology tests if done by GEMS Network provider • Limited to R189 376 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Includes cost of radiology, medical technologists and immuno-suppressantsSpecialists • Consultations and visits • UnlimitedSurgical procedures (including maxillo-facial surgery) • Unlimited • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery

Alcohol and drug dependencies • Subject to use of a 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 registration with relevant statutory bodies • Shared with in-hospital allied health services limit of R1 173 per family per year • Includes medicine prescribed by allied health professionalsCircumcision (to help prevent HIV infection) • Global fee of R1 068, which includes all related costs of post-procedure care within month of procedure • Out-of-hospital Benefit onlyDay-to-day Block Benefit • Out-of-hospital GP and specialist consultations and visits, physiotherapy, maternity, audiology, occupational therapy, speech therapy, pathology and medical technology • Limited to R3 308 per beneficiary and R6 616 per family per year • Benefit is pro-rated from join date- Audiology, occupational therapy and speech therapy • Occupational or speech therapy performed in-hospital will be paid from the in-hospital benefit • Limit of R1 613 per beneficiary per year and R3 233 per family per year shared with pathology and medical technology • Sub-limit of R1 297 per beneficiary and R2 592 per family per year - GP Network Extender Benefit • For beneficiaries with chronic conditions registered on Chronic Medicine Programme • 1 additional GP consultation at a GEMS Network provider once Block Benefit is exhausted- Maternity • Ante-natal and post-natal specialist visits • Subject to PMBs • Shared with GP services • Subject to registration on the Maternity Programme • Includes 2 x 2D ultrasound scans per pregnancy - Pathology and medical technology • Limit of R1 613 per beneficiary per year and R3 233 per family per year shared with audiology, occupational therapy and speech therapy • Includes liquid based cytology Pap smear - Physiotherapy • Physiotherapy performed in-hospital or instead of hospitalisation will be paid from in-hospital benefit • Sub-limit of R1 613 per beneficiary and R3 222 per family per yearDental 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 696 per beneficiary per year • Conservative and restorative dentistry not to exceed R1 760 per beneficiary per year • Excludes osseo-integrated implants, all implant-related procedures and orthognatic surgery • No pre-authorisation required for metal base dentures • Lingual and labial frenectomies under general anaesthesia for children under the age of 8 subject to managed healthcare programme• 200% of Scheme rate for treatment of bony impactions of third molars under conscious sedationEmergency assistance (road and air) • Call 0800 44 4367• Subject to use of emergency services DSP • Unlimited HIV infection, AIDS and related illnessInfertility • Subject to use of DSPMedical and surgical appliances and external prosthesis• Includes hearing aids, wheelchairs, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment and external prostheses • In- and out-of-hospital • Shared with in-hospital internal prosthesis limit of R30 068 per family per year • Sub-limit of R11 732 for medical and surgical appliances per family per year

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• Shared with in-hospital mental health limit of R13 256 per family per year • Sub-limit of R3 931 for out-of-hospital psychologist consultationsOptical services • Frames, lenses and contact lenses (permanent and disposable) • Refractive eye surgery and eye examinations • Either spectacles or contact lenses (not both) can be claimed in a benefit year • Sub-limit of R1 760 per beneficiary every second year and annual limit of R3 519 per family • Frames not to exceed R1 089 • Limited to 1 eye examination per beneficiary per year • Excludes variable tint and photochromic lenses • Benefit not pro-rated • Post cataract surgery, PMB provides up to the cost of bifocal lens and not more than R842 for both lens and frame, with a sub-limit of R167 for framePrescribed medicine and injection material • Prescribed and administered by a professional legally entitled to do so• Subject to MPL and MEL- Acute medical conditions • Subject to formulary • Limit of R2 651 per beneficiary and R7 954 per family per year • 30% co-payment on out-of-formulary medicine • Dispensing fee limited to 30% up to R32 per line item- Chronic medical conditions • CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of the Network or courier pharmacy • Limit of R7 954 per beneficiary and R16 014 per family per year • 30% co-payment on out-of-formulary medicine and voluntary use of non-DSP- Contraceptives • Subject to formulary • Subject to acute medicine benefit limit • Sub-limit of R2 011 per beneficiary per year- Prescribed medicine from hospital stay (TTO) • Included in acute medicine benefit limit • TTO limited to 7 days- Self-medicine (OTC) • Subject to formulary • Subject to acute medicine benefit limit and sub-limit of R863 per beneficiary per yearPreventative care service • Serum cholesterol, bone density scan, Pap smear, prostate specific antigen, glaucoma screening, serum glucose and mammogram and other screenings according to evidence based standard practice • Limited to 1 of each of the stated preventative services per beneficiary per year • Benefit rolls over 3 calendar years and tests may only be done once in the 3 year period • Pap smears (including liquid based cytology) may be done annuallyRadiology (advanced) • 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 907 per family per yearRadiology (basic) • X-rays and soft tissue ultrasound scans • 2 x 2D ultrasound scans provided for by maternity benefit • Annual sub-limit of R2 640 per beneficiary and R4 839 per family per year

OUT-OF-HOSPITAL BENEFITS

Glossary (word list)ACDLAdditional chronic disease list. A list of chronic diseases the Scheme covers in addition to the CDL conditions.

Benefit optionEach of the five GEMS benefit options - namely Sapphire, Beryl, Ruby, Emerald and Onyx - have a different range of healthcare benefits.

Benefit scheduleA listing of the benefits provided for by each benefit option.

CDLChronic disease list. A list of the 26 specific chronic diseases Schemes need to provide a minimum level of cover for, as stated by law.

CT and MRI scansSpecialised and more advanced type of “x-rays”.

DMPDisease Management Programme. Specific care programmes to help members manage various chronic diseases and conditions.

PMBsPrescribed minimum benefits. Basic benefits that all medical schemes in South Africa, must cover according to the law.

DSPDesignated service provider. A healthcare service provider the Scheme has an agreement with to provide Prescribed minimum benefits to members at specific prices.

DTPDiagnosis and Treatment Pairs are a list of the 270 PMB conditions in the Medical Schemes Act linked to the broad treatment definition.

MELMedicine exclusion list. A list of medicines that GEMS does not cover.

MPLMedicine price list. A reference list we use to work out the prices of groups of medicines.

Pre-authorisation request (PAR)The process of informing GEMS of a planned procedure before the event so that we can assess your benefit entilement. Pre-authorisation must be obtained at least 48 hours before the event. In emergency cases authorisation must be obtained within one working day after the event. Failing to get authorisation will incur a co-payment of R1 000 per admission to hospital.

PDFProfessional dispensing fee. A maximum fee that a pharmacist or dispensing doctor may charge for their services, as set out in South African law.

PMSAPersonal medical savings account. The portion of your monthly contribution allocated to a savings account held in your name. This account is to pay for your out-of-hospital medical expenses. This only applies to Ruby option.

Scheme rateThe price agreed to by the Scheme for the payment of healthcare services given by healthcare service providers to members of the Scheme.

SEPSingle exit price. The one price that a medicine manufacturer or importer charges for medicine to all its pharmacies. This price is set out in South African law.

TTOTreatment taken out. The medicine you receive when you are discharged from hospital. Usually last for 7 days.

Accessible info- Convenience for you

Prescribed minimum benefits (PMBs)100% of Scheme rate • Service must be provided by a DSPPMBs override all other benefit limitations

Please refer to the glossary (word list) at the end for an explanation of the terms and abbreviations.

Pre-authorisation is needed100% of Scheme rate

Limited to PMBsSubject to managed care rules

What’s new in 2013?1. A5.5%increaseinbenefitlimits.2. Asub-limitofR15000underorganandtissuetransplantsforlocalandimportedcornealgrafts.3. Thereisnowanin-hospitaldentistryinclusionoflingualandlabialfrenectomiesundergeneral anaesthesiaforchildrenundertheageofeight.4. Out-of-hospitaltreatmentofbony,impactedthirdmolarsunderconscioussedationwillbe coveredat200%oftheSchemerate.5. Post-surgicalhomenursingcareasanalternativetohospitalisationisnowcovered.6. Preventativecareservices,suchaspapsmearsandotherstandardscreenings,willnowbecovered,subjecttothe managedcarerulesoftheScheme.7. TheDay-to-dayBlockBenefitincludestheGPNetworkExtenderBenefitforbeneficiariesregisteredontheChronic MedicineProgramme.8. Alzheimer’shasbeenaddedtotheACDL.

Bringing health within your reach

Emerald is the traditional option designed to offer comprehensive cover which offers access to care at the provider of your choice, subject to benefits and Scheme rules.

Read all about your benefits and find answers to your most frequently asked questions in this easy to read, pocket size mini-guide that you can refer to - anytime, anywhere!

IN-HOSPITAL BENEFITS

Annual in-hospital benefit • Public and private hospitals, registered unattached theatres and day clinics • Accommodation in private ward subject to motivation by attending practitioner and managed care rules • Unlimited • R12 623 per beneficiary annual limit for non-PMB, 1 day admissions, not pro-ratedAllied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Shared with out-of-hospital limit of R1 173 per family per year • Includes medicines prescribed by allied health professionalsAlternatives to hospitalisation (hospice, sub-acute hospitals and private nursing) • Excludes frail care and recuperative holidays • Includes physical rehabilitation for approved conditions and post-surgical home nursing care • UnlimitedBlood transfusion • Includes Erythropoietin (hormone that promotes the formation of red blood cells) • UnlimitedBreast reduction • UnlimitedDentistry (conservative, restorative and specialised)• General anaesthesia and conscious sedation subject to managed care rules • Only applicable to beneficiaries under the age of 8 years, with severe trauma or impacted third molars• Lingual and labial frenectomies under general anaesthesia for children under the age of 8 subject to managed healthcare programme • Subject to list of approved services and use of day theatres • Shared with out-of-hospital dentistry• Limited to R3 696 per beneficiary per year • Conservative and restorative dentistry not to exceed R1 760 per beneficiary per year • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery Emergency services (casualty department) • Will be paid from out-of-hospital GP Services if pre-authorisation is not obtained• Admission subject to pre-authorisationGeneral practitioners (GPs) • Consultations and visits • Unlimited

Maternity benefits (including midwife) • Subject to registration on the Maternity Programme • Includes hospital, home birth and registered birthing unit • Hospital birth unlimited, includes complications for mother and newborn • Home birth limited to R7 755 per beneficiary per year • Elective caesarean may be subject to second opinionMedical technologist • Subject to case management • Unlimited

Mental health • Accommodation, theatre fees, medicine, professional fees from GPs, psychiatrists, psychologists and registered counsellors • Limited to R13 256 per family per year for non-PMBs • Maximum of 3 days hospitalisation by GPOncology (chemo and radiotherapy) • In- and out-of-hospital • Includes medicine and materials • Subject to registration on managed care programme • Limited to R265 134 per family per year • Specialised medicine sub-limit of R180 366 per family per year • Includes cost of pathology, radiology, medical technologist and oncology medicine • Subject to MPLOrgan and tissue transplants • Subject to clinical guidelines used in public facilities • Includes materials • Limited to R441 886 per beneficiary per year • Sub-limit of R15 000 per beneficiary per year for corneal grafts, subject to managed care rules • Limit includes all costs associated with transplant including immuno-suppressants, subject to PMBs • Organ harvesting limited to RSA, except for cornea tissuePathology • Unlimited Physiotherapy • Limited to R3 575 per beneficiary per year

Prostheses • Includes prostheses and surgically implanted internal devices, including all temporary prostheses and all temporary or permanent devices used to assist with delivery of internal prostheses • Shared with medical and surgical appliances as well as out-of-hospital external prostheses limit of R30 068 per family per year • Scheme may arrange supply of prostheses • Bone cement paid from in-hospital benefitsRadiology (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 • Shared with out-of-hospital advanced radiology • Limited to R15 907 per family per yearRadiology (basic) • Unlimited Renal dialysis • Subject to clinical guideline used in public facilities • In- and out-of-hospital • Includes materials • Includes related pathology tests if done by GEMS Network provider • Limited to R189 376 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Includes cost of radiology, medical technologists and immuno-suppressantsSpecialists • Consultations and visits • UnlimitedSurgical procedures (including maxillo-facial surgery) • Unlimited • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery

Alcohol and drug dependencies • Subject to use of a 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 registration with relevant statutory bodies • Shared with in-hospital allied health services limit of R1 173 per family per year • Includes medicine prescribed by allied health professionalsCircumcision (to help prevent HIV infection) • Global fee of R1 068, which includes all related costs of post-procedure care within month of procedure • Out-of-hospital Benefit onlyDay-to-day Block Benefit • Out-of-hospital GP and specialist consultations and visits, physiotherapy, maternity, audiology, occupational therapy, speech therapy, pathology and medical technology • Limited to R3 308 per beneficiary and R6 616 per family per year • Benefit is pro-rated from join date- Audiology, occupational therapy and speech therapy • Occupational or speech therapy performed in-hospital will be paid from the in-hospital benefit • Limit of R1 613 per beneficiary per year and R3 233 per family per year shared with pathology and medical technology • Sub-limit of R1 297 per beneficiary and R2 592 per family per year - GP Network Extender Benefit • For beneficiaries with chronic conditions registered on Chronic Medicine Programme • 1 additional GP consultation at a GEMS Network provider once Block Benefit is exhausted- Maternity • Ante-natal and post-natal specialist visits • Subject to PMBs • Shared with GP services • Subject to registration on the Maternity Programme • Includes 2 x 2D ultrasound scans per pregnancy - Pathology and medical technology • Limit of R1 613 per beneficiary per year and R3 233 per family per year shared with audiology, occupational therapy and speech therapy • Includes liquid based cytology Pap smear - Physiotherapy • Physiotherapy performed in-hospital or instead of hospitalisation will be paid from in-hospital benefit • Sub-limit of R1 613 per beneficiary and R3 222 per family per yearDental 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 696 per beneficiary per year • Conservative and restorative dentistry not to exceed R1 760 per beneficiary per year • Excludes osseo-integrated implants, all implant-related procedures and orthognatic surgery • No pre-authorisation required for metal base dentures • Lingual and labial frenectomies under general anaesthesia for children under the age of 8 subject to managed healthcare programme• 200% of Scheme rate for treatment of bony impactions of third molars under conscious sedationEmergency assistance (road and air) • Call 0800 44 4367• Subject to use of emergency services DSP • Unlimited HIV infection, AIDS and related illnessInfertility • Subject to use of DSPMedical and surgical appliances and external prosthesis• Includes hearing aids, wheelchairs, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment and external prostheses • In- and out-of-hospital • Shared with in-hospital internal prosthesis limit of R30 068 per family per year • Sub-limit of R11 732 for medical and surgical appliances per family per year

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• Shared with in-hospital mental health limit of R13 256 per family per year • Sub-limit of R3 931 for out-of-hospital psychologist consultationsOptical services • Frames, lenses and contact lenses (permanent and disposable) • Refractive eye surgery and eye examinations • Either spectacles or contact lenses (not both) can be claimed in a benefit year • Sub-limit of R1 760 per beneficiary every second year and annual limit of R3 519 per family • Frames not to exceed R1 089 • Limited to 1 eye examination per beneficiary per year • Excludes variable tint and photochromic lenses • Benefit not pro-rated • Post cataract surgery, PMB provides up to the cost of bifocal lens and not more than R842 for both lens and frame, with a sub-limit of R167 for framePrescribed medicine and injection material • Prescribed and administered by a professional legally entitled to do so• Subject to MPL and MEL- Acute medical conditions • Subject to formulary • Limit of R2 651 per beneficiary and R7 954 per family per year • 30% co-payment on out-of-formulary medicine • Dispensing fee limited to 30% up to R32 per line item- Chronic medical conditions • CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of the Network or courier pharmacy • Limit of R7 954 per beneficiary and R16 014 per family per year • 30% co-payment on out-of-formulary medicine and voluntary use of non-DSP- Contraceptives • Subject to formulary • Subject to acute medicine benefit limit • Sub-limit of R2 011 per beneficiary per year- Prescribed medicine from hospital stay (TTO) • Included in acute medicine benefit limit • TTO limited to 7 days- Self-medicine (OTC) • Subject to formulary • Subject to acute medicine benefit limit and sub-limit of R863 per beneficiary per yearPreventative care service • Serum cholesterol, bone density scan, Pap smear, prostate specific antigen, glaucoma screening, serum glucose and mammogram and other screenings according to evidence based standard practice • Limited to 1 of each of the stated preventative services per beneficiary per year • Benefit rolls over 3 calendar years and tests may only be done once in the 3 year period • Pap smears (including liquid based cytology) may be done annuallyRadiology (advanced) • 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 907 per family per yearRadiology (basic) • X-rays and soft tissue ultrasound scans • 2 x 2D ultrasound scans provided for by maternity benefit • Annual sub-limit of R2 640 per beneficiary and R4 839 per family per year

OUT-OF-HOSPITAL BENEFITS

Glossary (word list)ACDLAdditional chronic disease list. A list of chronic diseases the Scheme covers in addition to the CDL conditions.

Benefit optionEach of the five GEMS benefit options - namely Sapphire, Beryl, Ruby, Emerald and Onyx - have a different range of healthcare benefits.

Benefit scheduleA listing of the benefits provided for by each benefit option.

CDLChronic disease list. A list of the 26 specific chronic diseases Schemes need to provide a minimum level of cover for, as stated by law.

CT and MRI scansSpecialised and more advanced type of “x-rays”.

DMPDisease Management Programme. Specific care programmes to help members manage various chronic diseases and conditions.

PMBsPrescribed minimum benefits. Basic benefits that all medical schemes in South Africa, must cover according to the law.

DSPDesignated service provider. A healthcare service provider the Scheme has an agreement with to provide Prescribed minimum benefits to members at specific prices.

DTPDiagnosis and Treatment Pairs are a list of the 270 PMB conditions in the Medical Schemes Act linked to the broad treatment definition.

MELMedicine exclusion list. A list of medicines that GEMS does not cover.

MPLMedicine price list. A reference list we use to work out the prices of groups of medicines.

Pre-authorisation request (PAR)The process of informing GEMS of a planned procedure before the event so that we can assess your benefit entilement. Pre-authorisation must be obtained at least 48 hours before the event. In emergency cases authorisation must be obtained within one working day after the event. Failing to get authorisation will incur a co-payment of R1 000 per admission to hospital.

PDFProfessional dispensing fee. A maximum fee that a pharmacist or dispensing doctor may charge for their services, as set out in South African law.

PMSAPersonal medical savings account. The portion of your monthly contribution allocated to a savings account held in your name. This account is to pay for your out-of-hospital medical expenses. This only applies to Ruby option.

Scheme rateThe price agreed to by the Scheme for the payment of healthcare services given by healthcare service providers to members of the Scheme.

SEPSingle exit price. The one price that a medicine manufacturer or importer charges for medicine to all its pharmacies. This price is set out in South African law.

TTOTreatment taken out. The medicine you receive when you are discharged from hospital. Usually last for 7 days.

Accessible info- Convenience for you

Prescribed minimum benefits (PMBs)100% of Scheme rate • Service must be provided by a DSPPMBs override all other benefit limitations

Please refer to the glossary (word list) at the end for an explanation of the terms and abbreviations.

Pre-authorisation is needed100% of Scheme rate

Limited to PMBsSubject to managed care rules

What’s new in 2013?1. A5.5%increaseinbenefitlimits.2. Asub-limitofR15000underorganandtissuetransplantsforlocalandimportedcornealgrafts.3. Thereisnowanin-hospitaldentistryinclusionoflingualandlabialfrenectomiesundergeneral anaesthesiaforchildrenundertheageofeight.4. Out-of-hospitaltreatmentofbony,impactedthirdmolarsunderconscioussedationwillbe coveredat200%oftheSchemerate.5. Post-surgicalhomenursingcareasanalternativetohospitalisationisnowcovered.6. Preventativecareservices,suchaspapsmearsandotherstandardscreenings,willnowbecovered,subjecttothe managedcarerulesoftheScheme.7. TheDay-to-dayBlockBenefitincludestheGPNetworkExtenderBenefitforbeneficiariesregisteredontheChronic MedicineProgramme.8. Alzheimer’shasbeenaddedtotheACDL.

Bringing health within your reach

Emerald is the traditional option designed to offer comprehensive cover which offers access to care at the provider of your choice, subject to benefits and Scheme rules.

Read all about your benefits and find answers to your most frequently asked questions in this easy to read, pocket size mini-guide that you can refer to - anytime, anywhere!

IN-HOSPITAL BENEFITS

Annual in-hospital benefit • Public and private hospitals, registered unattached theatres and day clinics • Accommodation in private ward subject to motivation by attending practitioner and managed care rules • Unlimited • R12 623 per beneficiary annual limit for non-PMB, 1 day admissions, not pro-ratedAllied health services • Includes chiropractors, dieticians, homeopaths, chiropodists, phytotherapists, reflexologists, social workers, naturopaths, orthoptists, acupuncturists, ayuverdic practitioners, osteopaths, aromatherapists, therapeutic massage therapists, Chinese medicine practitioners • Shared with out-of-hospital limit of R1 173 per family per year • Includes medicines prescribed by allied health professionalsAlternatives to hospitalisation (hospice, sub-acute hospitals and private nursing) • Excludes frail care and recuperative holidays • Includes physical rehabilitation for approved conditions and post-surgical home nursing care • UnlimitedBlood transfusion • Includes Erythropoietin (hormone that promotes the formation of red blood cells) • UnlimitedBreast reduction • UnlimitedDentistry (conservative, restorative and specialised)• General anaesthesia and conscious sedation subject to managed care rules • Only applicable to beneficiaries under the age of 8 years, with severe trauma or impacted third molars• Lingual and labial frenectomies under general anaesthesia for children under the age of 8 subject to managed healthcare programme • Subject to list of approved services and use of day theatres • Shared with out-of-hospital dentistry• Limited to R3 696 per beneficiary per year • Conservative and restorative dentistry not to exceed R1 760 per beneficiary per year • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery Emergency services (casualty department) • Will be paid from out-of-hospital GP Services if pre-authorisation is not obtained• Admission subject to pre-authorisationGeneral practitioners (GPs) • Consultations and visits • Unlimited

Maternity benefits (including midwife) • Subject to registration on the Maternity Programme • Includes hospital, home birth and registered birthing unit • Hospital birth unlimited, includes complications for mother and newborn • Home birth limited to R7 755 per beneficiary per year • Elective caesarean may be subject to second opinionMedical technologist • Subject to case management • Unlimited

Mental health • Accommodation, theatre fees, medicine, professional fees from GPs, psychiatrists, psychologists and registered counsellors • Limited to R13 256 per family per year for non-PMBs • Maximum of 3 days hospitalisation by GPOncology (chemo and radiotherapy) • In- and out-of-hospital • Includes medicine and materials • Subject to registration on managed care programme • Limited to R265 134 per family per year • Specialised medicine sub-limit of R180 366 per family per year • Includes cost of pathology, radiology, medical technologist and oncology medicine • Subject to MPLOrgan and tissue transplants • Subject to clinical guidelines used in public facilities • Includes materials • Limited to R441 886 per beneficiary per year • Sub-limit of R15 000 per beneficiary per year for corneal grafts, subject to managed care rules • Limit includes all costs associated with transplant including immuno-suppressants, subject to PMBs • Organ harvesting limited to RSA, except for cornea tissuePathology • Unlimited Physiotherapy • Limited to R3 575 per beneficiary per year

Prostheses • Includes prostheses and surgically implanted internal devices, including all temporary prostheses and all temporary or permanent devices used to assist with delivery of internal prostheses • Shared with medical and surgical appliances as well as out-of-hospital external prostheses limit of R30 068 per family per year • Scheme may arrange supply of prostheses • Bone cement paid from in-hospital benefitsRadiology (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 • Shared with out-of-hospital advanced radiology • Limited to R15 907 per family per yearRadiology (basic) • Unlimited Renal dialysis • Subject to clinical guideline used in public facilities • In- and out-of-hospital • Includes materials • Includes related pathology tests if done by GEMS Network provider • Limited to R189 376 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Includes cost of radiology, medical technologists and immuno-suppressantsSpecialists • Consultations and visits • UnlimitedSurgical procedures (including maxillo-facial surgery) • Unlimited • Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery

Alcohol and drug dependencies • Subject to use of a 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 registration with relevant statutory bodies • Shared with in-hospital allied health services limit of R1 173 per family per year • Includes medicine prescribed by allied health professionalsCircumcision (to help prevent HIV infection) • Global fee of R1 068, which includes all related costs of post-procedure care within month of procedure • Out-of-hospital Benefit onlyDay-to-day Block Benefit • Out-of-hospital GP and specialist consultations and visits, physiotherapy, maternity, audiology, occupational therapy, speech therapy, pathology and medical technology • Limited to R3 308 per beneficiary and R6 616 per family per year • Benefit is pro-rated from join date- Audiology, occupational therapy and speech therapy • Occupational or speech therapy performed in-hospital will be paid from the in-hospital benefit • Limit of R1 613 per beneficiary per year and R3 233 per family per year shared with pathology and medical technology • Sub-limit of R1 297 per beneficiary and R2 592 per family per year - GP Network Extender Benefit • For beneficiaries with chronic conditions registered on Chronic Medicine Programme • 1 additional GP consultation at a GEMS Network provider once Block Benefit is exhausted- Maternity • Ante-natal and post-natal specialist visits • Subject to PMBs • Shared with GP services • Subject to registration on the Maternity Programme • Includes 2 x 2D ultrasound scans per pregnancy - Pathology and medical technology • Limit of R1 613 per beneficiary per year and R3 233 per family per year shared with audiology, occupational therapy and speech therapy • Includes liquid based cytology Pap smear - Physiotherapy • Physiotherapy performed in-hospital or instead of hospitalisation will be paid from in-hospital benefit • Sub-limit of R1 613 per beneficiary and R3 222 per family per yearDental 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 696 per beneficiary per year • Conservative and restorative dentistry not to exceed R1 760 per beneficiary per year • Excludes osseo-integrated implants, all implant-related procedures and orthognatic surgery • No pre-authorisation required for metal base dentures • Lingual and labial frenectomies under general anaesthesia for children under the age of 8 subject to managed healthcare programme• 200% of Scheme rate for treatment of bony impactions of third molars under conscious sedationEmergency assistance (road and air) • Call 0800 44 4367• Subject to use of emergency services DSP • Unlimited HIV infection, AIDS and related illnessInfertility • Subject to use of DSPMedical and surgical appliances and external prosthesis• Includes hearing aids, wheelchairs, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment and external prostheses • In- and out-of-hospital • Shared with in-hospital internal prosthesis limit of R30 068 per family per year • Sub-limit of R11 732 for medical and surgical appliances per family per year

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• Shared with in-hospital mental health limit of R13 256 per family per year • Sub-limit of R3 931 for out-of-hospital psychologist consultationsOptical services • Frames, lenses and contact lenses (permanent and disposable) • Refractive eye surgery and eye examinations • Either spectacles or contact lenses (not both) can be claimed in a benefit year • Sub-limit of R1 760 per beneficiary every second year and annual limit of R3 519 per family • Frames not to exceed R1 089 • Limited to 1 eye examination per beneficiary per year • Excludes variable tint and photochromic lenses • Benefit not pro-rated • Post cataract surgery, PMB provides up to the cost of bifocal lens and not more than R842 for both lens and frame, with a sub-limit of R167 for framePrescribed medicine and injection material • Prescribed and administered by a professional legally entitled to do so• Subject to MPL and MEL- Acute medical conditions • Subject to formulary • Limit of R2 651 per beneficiary and R7 954 per family per year • 30% co-payment on out-of-formulary medicine • Dispensing fee limited to 30% up to R32 per line item- Chronic medical conditions • CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of the Network or courier pharmacy • Limit of R7 954 per beneficiary and R16 014 per family per year • 30% co-payment on out-of-formulary medicine and voluntary use of non-DSP- Contraceptives • Subject to formulary • Subject to acute medicine benefit limit • Sub-limit of R2 011 per beneficiary per year- Prescribed medicine from hospital stay (TTO) • Included in acute medicine benefit limit • TTO limited to 7 days- Self-medicine (OTC) • Subject to formulary • Subject to acute medicine benefit limit and sub-limit of R863 per beneficiary per yearPreventative care service • Serum cholesterol, bone density scan, Pap smear, prostate specific antigen, glaucoma screening, serum glucose and mammogram and other screenings according to evidence based standard practice • Limited to 1 of each of the stated preventative services per beneficiary per year • Benefit rolls over 3 calendar years and tests may only be done once in the 3 year period • Pap smears (including liquid based cytology) may be done annuallyRadiology (advanced) • 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 907 per family per yearRadiology (basic) • X-rays and soft tissue ultrasound scans • 2 x 2D ultrasound scans provided for by maternity benefit • Annual sub-limit of R2 640 per beneficiary and R4 839 per family per year

OUT-OF-HOSPITAL BENEFITS

Glossary (word list)ACDLAdditional chronic disease list. A list of chronic diseases the Scheme covers in addition to the CDL conditions.

Benefit optionEach of the five GEMS benefit options - namely Sapphire, Beryl, Ruby, Emerald and Onyx - have a different range of healthcare benefits.

Benefit scheduleA listing of the benefits provided for by each benefit option.

CDLChronic disease list. A list of the 26 specific chronic diseases Schemes need to provide a minimum level of cover for, as stated by law.

CT and MRI scansSpecialised and more advanced type of “x-rays”.

DMPDisease Management Programme. Specific care programmes to help members manage various chronic diseases and conditions.

PMBsPrescribed minimum benefits. Basic benefits that all medical schemes in South Africa, must cover according to the law.

DSPDesignated service provider. A healthcare service provider the Scheme has an agreement with to provide Prescribed minimum benefits to members at specific prices.

DTPDiagnosis and Treatment Pairs are a list of the 270 PMB conditions in the Medical Schemes Act linked to the broad treatment definition.

MELMedicine exclusion list. A list of medicines that GEMS does not cover.

MPLMedicine price list. A reference list we use to work out the prices of groups of medicines.

Pre-authorisation request (PAR)The process of informing GEMS of a planned procedure before the event so that we can assess your benefit entilement. Pre-authorisation must be obtained at least 48 hours before the event. In emergency cases authorisation must be obtained within one working day after the event. Failing to get authorisation will incur a co-payment of R1 000 per admission to hospital.

PDFProfessional dispensing fee. A maximum fee that a pharmacist or dispensing doctor may charge for their services, as set out in South African law.

PMSAPersonal medical savings account. The portion of your monthly contribution allocated to a savings account held in your name. This account is to pay for your out-of-hospital medical expenses. This only applies to Ruby option.

Scheme rateThe price agreed to by the Scheme for the payment of healthcare services given by healthcare service providers to members of the Scheme.

SEPSingle exit price. The one price that a medicine manufacturer or importer charges for medicine to all its pharmacies. This price is set out in South African law.

TTOTreatment taken out. The medicine you receive when you are discharged from hospital. Usually last for 7 days.

Accessible info- Convenience for you

Bringing health within your reach

If you need to go to hospital, it is important to remember that GEMS members need pre-authorisation for:• All hospital visits;• Out-patient visits to a hospital;• MRI scans, CT scans or radio-isotope studies;• In-hospital physiotherapy;• Ambulance transportation; and• Specialised dentistry.

Pre-authorisations must be requested by either you or the healthcare service provider at least 48 hours before you go to hospital or for a scan. If you need to go for emergency treatment or be admitted to hospital over a weekend, public holiday or at night, you or a family member must call on the first working day after the incident. If you do not get pre-authorisation for a planned event 48 hours before or authorisation on the first working day after an emergency event, you will pay a penalty.

The Friends of GEMS programme was designed to give members access to Network providers and affordable healthcare service providers in their area who have agreed to only charge GEMS members the Scheme rate. All you need to do to find one of these Friends of GEMS in your area is to send an SMS to 33489.

For example, if you live in Seshego and you need to see a dentist, you simply SMS: member number, dentist, Seshego. You will receive a reply message via SMS with the contact details of up to three dentists in the Seshego area who are Friends of GEMS. If there are no healthcare service providers in the area you asked for, GEMS will look for “Friends” in the surrounding areas. This will happen without you having to send another SMS (each SMS will cost you R1.50).

What is chronic medicine?Chronic medicine is:• Medicine for life-threatening illnesses, like diabetes;• Medicine used on an ongoing basis to treat disabling chronic illnesses that significantly affect productivity and quality of life; and/or• Very expensive, short-term medicine (Usually prescribed for more than three months) that will prevent other expensive treatment, such as hospitalisation.

Chronic medicines must be pre-authorised by the Medicine Management department and not all medicines are paid in full even if pre-authorisation was obtained. Always check with your doctor to see if the most cost effective medicine is prescribed according to the Medicine Price List (MPL) and the formulary list of medicines so that you do not need to pay any amount out of your own pocket.

How do I apply to get authorisation for my chronic medicines?• You and your doctor should accurately complete and sign a chronic medicine benefit application form, which is available on the GEMS website at www.gems.gov.za, or call GEMS on 0860 00 4367 and ask for a chronic medicine benefit application form.• Fax your completed and signed form, supporting documents and the matching doctor’s prescription to 0861 00 4367.• Registration on the Chronic Medicine Programme depends on the Scheme Rules and managed care guidelines. If your application is approved, the Scheme will give you a choice of receiving your medicine through our Courier pharmacy or your nearest GEMS Network pharmacy. Once you have indicated your choice, you can go and collect your medicines at your nearest Network pharmacy if that was your choice. If you chose the Courier pharmacy they will contact you to make medicine delivery arrangements.• Please ensure that the Scheme has your current contact details.

How do I get my authorised chronic medicine? Once your chronic medicine has been approved, you will be issued with a medicine access card which lists the approved medicines. You must fax a new prescription to 0861 00 4367 every six months to make sure that you keep on receiving your medicine. Remember to provide your member number and contact details.

What if my chronic medicine request has been declined?• A letter will be sent to you and your prescribing doctor explaining why your application was declined.• If more clinical information is needed, your request will be reconsidered once all the relevant information has been received from your doctor.• Your doctor can call the healthcare service provider line on 0860 00 4367 for help.

What if my authorised chronic medicine changes?• You must let GEMS know if your chronic medicine changes in any way.• The quickest way to let us know of changes is for your prescribing doctor to contact the clinical staff on the healthcare service provider line on 0860 00 4367. The change will be processed within 24 hours and, if approved you can collect your medicine at your nearest Network pharmacy or the courier pharmacy will be able to process your delivery. • Remember that a repeatable doctor’s prescription for the new medicine must be faxed to the Scheme at 0861 00 4367, as both the Network and Courier pharmacy may not dispense medicine without a valid script.• An updated medicine access card will be mailed to you.• It is not necessary to request a new medicine access card if the authorised medicine is replaced by a generic equivalent within the same medicine price list (MPL) group.• For a complete list of chronic diseases covered, please check your member guide.

There is a specific Ruby, Emerald and Onyx (REO) Network which is made up of general practitioners (GPs) who have agreed to charge the Scheme rate and follow the managed care rules applicable to the GEMS Network relevant for these options.

You do not have to use the Network providers, but if you do, you can be assured that you will be using clinically appropriate and cost effective healthcare services.

All Network providers will display a GEMS Network logo/sticker in their practice window or door, making it easy for you to identify them.

Benefit check service • check your benefits to make them last

Friends of GEMS

Claiming made easy: frequently asked questions

Claim alert SMS

Get hospital pre-authorisation

How to apply for chronic medicine

A quick and easy way to check whether you have benefits available for any treatment you need is to use the SMS benefit check service. This service lets you know exactly what benefits you still have available for a specific benefit category. If you need to visit a doctor or to have a procedure done, you can check your available benefits by simply sending an SMS to 33489 (each SMS will cost you R1.50).

You can only use this service with the cellphone number on our records. Please make sure we have your current contact details so that you can use this convenient service.

You simply SMS: benefit, member number, keyword (in table below), dependant code and we will get back to you with your available benefits. A full guide to the benefit check service is available on the GEMS website at www.gems.gov.za.

Savings / PMSADay-to-day benefitAcute medicineChronic medicineAllied health servicesBasic dentistrySpecialised dentistryOptical benefitHospitalPMB

SaveDay

AcuteChronic

AlliedBasic

SpecialOptical

HospitalPMB

Keyword benefit category

Who can submit claims?Claims can be submitted by the member or the healthcare service provider.

How is a claim processed?The Claims Department receives the claim and assesses it according to the Scheme Rules. If the Scheme Rules allow, the claim will then be paid.

When are claims paid?Twice a month.

Are medicine claims processed immediately?Your pharmacy can send medicine claims to us electronically at the point of sale. The Scheme Rules will be applied immediately, so you will find out if GEMS will pay for the medicine right away. This means that you will get your medicine immediately, if you have available benefits, GEMS will pay for the medicine without you having to pay for it in cash.

How do I get a refund if I paid for a claim?If you have paid your healthcare service provider, please send your claim and proof of payment to GEMS as soon as possible. Refund payments to members are made electronically to the bank account that members have provided to the Scheme. You need to ensure that we have your accurate and up-to-date banking details.

What information must be included on a claim?When you submit a claim to GEMS, ensure that the following information is contained on the healthcare service provider’s invoice/claim:• Your member number, surname and initials;• The patient’s name and beneficiary code;• The Scheme name and your option;• The name and valid practice number of the healthcare service provider;• The date of service;• The nature and cost of treatment;• The pre-authorisation number, if applicable;• The tariff code and the relevant ICD-10 code;• Your signature to confirm that the account is valid; and• If you paid for the service, attach proof of payment.

How do I submit my claims?By post: All claims should be submitted to GEMS, Private Bag X782, Cape Town, 8000.By fax: 0861 00 4367By email: enquiries@gems.gov.zaBy hand: You can also deliver your claims to one of our regional offices.

Remember:Claims must be submitted to GEMS within four months from the date of service.

There are many advantages to visiting a GEMS Network GP:• You will not have to pay any out-of-pocket expenses for your consultations.• Your GEMS Network GP has agreed to provide excellent quality care to GEMS members at Scheme rates and not to charge you any co-payments or additional costs.• All GEMS Network GPs are willing to have their practice profiled (peer reviewed) and, where necessary, to accept guidance by their colleagues (peer mentoring) to improve their practice.• GPs who are profiled and achieve the highest status are rewarded with a higher consultation fee - at no additional cost to you, the GEMS member.

You can also find aFriend of GEMS online at

www.gems.gov.za

To receive

claim alert SMSs,

please call

0860 00 4367

Members can receive claim alert SMSs when GEMS processes their claims. The SMS acknowledges receipt of claims but is not a guarantee of payment. Ensure that you read your claim statements to see if your claim was paid or not. To receive claim alert SMSs, please call 0860 00 4367 and make sure that we have your current cellphone number.

Accessible info- Convenience for you

Bringing health within your reach

Bringing health within your reach

If you need to go to hospital, it is important to remember that GEMS members need pre-authorisation for:• All hospital visits;• Out-patient visits to a hospital;• MRI scans, CT scans or radio-isotope studies;• In-hospital physiotherapy;• Ambulance transportation; and• Specialised dentistry.

Pre-authorisations must be requested by either you or the healthcare service provider at least 48 hours before you go to hospital or for a scan. If you need to go for emergency treatment or be admitted to hospital over a weekend, public holiday or at night, you or a family member must call on the first working day after the incident. If you do not get pre-authorisation for a planned event 48 hours before or authorisation on the first working day after an emergency event, you will pay a penalty.

The Friends of GEMS programme was designed to give members access to Network providers and affordable healthcare service providers in their area who have agreed to only charge GEMS members the Scheme rate. All you need to do to find one of these Friends of GEMS in your area is to send an SMS to 33489.

For example, if you live in Seshego and you need to see a dentist, you simply SMS: member number, dentist, Seshego. You will receive a reply message via SMS with the contact details of up to three dentists in the Seshego area who are Friends of GEMS. If there are no healthcare service providers in the area you asked for, GEMS will look for “Friends” in the surrounding areas. This will happen without you having to send another SMS (each SMS will cost you R1.50).

What is chronic medicine?Chronic medicine is:• Medicine for life-threatening illnesses, like diabetes;• Medicine used on an ongoing basis to treat disabling chronic illnesses that significantly affect productivity and quality of life; and/or• Very expensive, short-term medicine (Usually prescribed for more than three months) that will prevent other expensive treatment, such as hospitalisation.

Chronic medicines must be pre-authorised by the Medicine Management department and not all medicines are paid in full even if pre-authorisation was obtained. Always check with your doctor to see if the most cost effective medicine is prescribed according to the Medicine Price List (MPL) and the formulary list of medicines so that you do not need to pay any amount out of your own pocket.

How do I apply to get authorisation for my chronic medicines?• You and your doctor should accurately complete and sign a chronic medicine benefit application form, which is available on the GEMS website at www.gems.gov.za, or call GEMS on 0860 00 4367 and ask for a chronic medicine benefit application form.• Fax your completed and signed form, supporting documents and the matching doctor’s prescription to 0861 00 4367.• Registration on the Chronic Medicine Programme depends on the Scheme Rules and managed care guidelines. If your application is approved, the Scheme will give you a choice of receiving your medicine through our Courier pharmacy or your nearest GEMS Network pharmacy. Once you have indicated your choice, you can go and collect your medicines at your nearest Network pharmacy if that was your choice. If you chose the Courier pharmacy they will contact you to make medicine delivery arrangements.• Please ensure that the Scheme has your current contact details.

How do I get my authorised chronic medicine? Once your chronic medicine has been approved, you will be issued with a medicine access card which lists the approved medicines. You must fax a new prescription to 0861 00 4367 every six months to make sure that you keep on receiving your medicine. Remember to provide your member number and contact details.

What if my chronic medicine request has been declined?• A letter will be sent to you and your prescribing doctor explaining why your application was declined.• If more clinical information is needed, your request will be reconsidered once all the relevant information has been received from your doctor.• Your doctor can call the healthcare service provider line on 0860 00 4367 for help.

What if my authorised chronic medicine changes?• You must let GEMS know if your chronic medicine changes in any way.• The quickest way to let us know of changes is for your prescribing doctor to contact the clinical staff on the healthcare service provider line on 0860 00 4367. The change will be processed within 24 hours and, if approved you can collect your medicine at your nearest Network pharmacy or the courier pharmacy will be able to process your delivery. • Remember that a repeatable doctor’s prescription for the new medicine must be faxed to the Scheme at 0861 00 4367, as both the Network and Courier pharmacy may not dispense medicine without a valid script.• An updated medicine access card will be mailed to you.• It is not necessary to request a new medicine access card if the authorised medicine is replaced by a generic equivalent within the same medicine price list (MPL) group.• For a complete list of chronic diseases covered, please check your member guide.

There is a specific Ruby, Emerald and Onyx (REO) Network which is made up of general practitioners (GPs) who have agreed to charge the Scheme rate and follow the managed care rules applicable to the GEMS Network relevant for these options.

You do not have to use the Network providers, but if you do, you can be assured that you will be using clinically appropriate and cost effective healthcare services.

All Network providers will display a GEMS Network logo/sticker in their practice window or door, making it easy for you to identify them.

Benefit check service • check your benefits to make them last

Friends of GEMS

Claiming made easy: frequently asked questions

Claim alert SMS

Get hospital pre-authorisation

How to apply for chronic medicine

A quick and easy way to check whether you have benefits available for any treatment you need is to use the SMS benefit check service. This service lets you know exactly what benefits you still have available for a specific benefit category. If you need to visit a doctor or to have a procedure done, you can check your available benefits by simply sending an SMS to 33489 (each SMS will cost you R1.50).

You can only use this service with the cellphone number on our records. Please make sure we have your current contact details so that you can use this convenient service.

You simply SMS: benefit, member number, keyword (in table below), dependant code and we will get back to you with your available benefits. A full guide to the benefit check service is available on the GEMS website at www.gems.gov.za.

Savings / PMSADay-to-day benefitAcute medicineChronic medicineAllied health servicesBasic dentistrySpecialised dentistryOptical benefitHospitalPMB

SaveDay

AcuteChronic

AlliedBasic

SpecialOptical

HospitalPMB

Keyword benefit category

Who can submit claims?Claims can be submitted by the member or the healthcare service provider.

How is a claim processed?The Claims Department receives the claim and assesses it according to the Scheme Rules. If the Scheme Rules allow, the claim will then be paid.

When are claims paid?Twice a month.

Are medicine claims processed immediately?Your pharmacy can send medicine claims to us electronically at the point of sale. The Scheme Rules will be applied immediately, so you will find out if GEMS will pay for the medicine right away. This means that you will get your medicine immediately, if you have available benefits, GEMS will pay for the medicine without you having to pay for it in cash.

How do I get a refund if I paid for a claim?If you have paid your healthcare service provider, please send your claim and proof of payment to GEMS as soon as possible. Refund payments to members are made electronically to the bank account that members have provided to the Scheme. You need to ensure that we have your accurate and up-to-date banking details.

What information must be included on a claim?When you submit a claim to GEMS, ensure that the following information is contained on the healthcare service provider’s invoice/claim:• Your member number, surname and initials;• The patient’s name and beneficiary code;• The Scheme name and your option;• The name and valid practice number of the healthcare service provider;• The date of service;• The nature and cost of treatment;• The pre-authorisation number, if applicable;• The tariff code and the relevant ICD-10 code;• Your signature to confirm that the account is valid; and• If you paid for the service, attach proof of payment.

How do I submit my claims?By post: All claims should be submitted to GEMS, Private Bag X782, Cape Town, 8000.By fax: 0861 00 4367By email: enquiries@gems.gov.zaBy hand: You can also deliver your claims to one of our regional offices.

Remember:Claims must be submitted to GEMS within four months from the date of service.

There are many advantages to visiting a GEMS Network GP:• You will not have to pay any out-of-pocket expenses for your consultations.• Your GEMS Network GP has agreed to provide excellent quality care to GEMS members at Scheme rates and not to charge you any co-payments or additional costs.• All GEMS Network GPs are willing to have their practice profiled (peer reviewed) and, where necessary, to accept guidance by their colleagues (peer mentoring) to improve their practice.• GPs who are profiled and achieve the highest status are rewarded with a higher consultation fee - at no additional cost to you, the GEMS member.

You can also find aFriend of GEMS online at

www.gems.gov.za

To receive

claim alert SMSs,

please call

0860 00 4367

Members can receive claim alert SMSs when GEMS processes their claims. The SMS acknowledges receipt of claims but is not a guarantee of payment. Ensure that you read your claim statements to see if your claim was paid or not. To receive claim alert SMSs, please call 0860 00 4367 and make sure that we have your current cellphone number.

Accessible info- Convenience for you

Bringing health within your reach

Bringing health within your reach

If you need to go to hospital, it is important to remember that GEMS members need pre-authorisation for:• All hospital visits;• Out-patient visits to a hospital;• MRI scans, CT scans or radio-isotope studies;• In-hospital physiotherapy;• Ambulance transportation; and• Specialised dentistry.

Pre-authorisations must be requested by either you or the healthcare service provider at least 48 hours before you go to hospital or for a scan. If you need to go for emergency treatment or be admitted to hospital over a weekend, public holiday or at night, you or a family member must call on the first working day after the incident. If you do not get pre-authorisation for a planned event 48 hours before or authorisation on the first working day after an emergency event, you will pay a penalty.

The Friends of GEMS programme was designed to give members access to Network providers and affordable healthcare service providers in their area who have agreed to only charge GEMS members the Scheme rate. All you need to do to find one of these Friends of GEMS in your area is to send an SMS to 33489.

For example, if you live in Seshego and you need to see a dentist, you simply SMS: member number, dentist, Seshego. You will receive a reply message via SMS with the contact details of up to three dentists in the Seshego area who are Friends of GEMS. If there are no healthcare service providers in the area you asked for, GEMS will look for “Friends” in the surrounding areas. This will happen without you having to send another SMS (each SMS will cost you R1.50).

What is chronic medicine?Chronic medicine is:• Medicine for life-threatening illnesses, like diabetes;• Medicine used on an ongoing basis to treat disabling chronic illnesses that significantly affect productivity and quality of life; and/or• Very expensive, short-term medicine (Usually prescribed for more than three months) that will prevent other expensive treatment, such as hospitalisation.

Chronic medicines must be pre-authorised by the Medicine Management department and not all medicines are paid in full even if pre-authorisation was obtained. Always check with your doctor to see if the most cost effective medicine is prescribed according to the Medicine Price List (MPL) and the formulary list of medicines so that you do not need to pay any amount out of your own pocket.

How do I apply to get authorisation for my chronic medicines?• You and your doctor should accurately complete and sign a chronic medicine benefit application form, which is available on the GEMS website at www.gems.gov.za, or call GEMS on 0860 00 4367 and ask for a chronic medicine benefit application form.• Fax your completed and signed form, supporting documents and the matching doctor’s prescription to 0861 00 4367.• Registration on the Chronic Medicine Programme depends on the Scheme Rules and managed care guidelines. If your application is approved, the Scheme will give you a choice of receiving your medicine through our Courier pharmacy or your nearest GEMS Network pharmacy. Once you have indicated your choice, you can go and collect your medicines at your nearest Network pharmacy if that was your choice. If you chose the Courier pharmacy they will contact you to make medicine delivery arrangements.• Please ensure that the Scheme has your current contact details.

How do I get my authorised chronic medicine? Once your chronic medicine has been approved, you will be issued with a medicine access card which lists the approved medicines. You must fax a new prescription to 0861 00 4367 every six months to make sure that you keep on receiving your medicine. Remember to provide your member number and contact details.

What if my chronic medicine request has been declined?• A letter will be sent to you and your prescribing doctor explaining why your application was declined.• If more clinical information is needed, your request will be reconsidered once all the relevant information has been received from your doctor.• Your doctor can call the healthcare service provider line on 0860 00 4367 for help.

What if my authorised chronic medicine changes?• You must let GEMS know if your chronic medicine changes in any way.• The quickest way to let us know of changes is for your prescribing doctor to contact the clinical staff on the healthcare service provider line on 0860 00 4367. The change will be processed within 24 hours and, if approved you can collect your medicine at your nearest Network pharmacy or the courier pharmacy will be able to process your delivery. • Remember that a repeatable doctor’s prescription for the new medicine must be faxed to the Scheme at 0861 00 4367, as both the Network and Courier pharmacy may not dispense medicine without a valid script.• An updated medicine access card will be mailed to you.• It is not necessary to request a new medicine access card if the authorised medicine is replaced by a generic equivalent within the same medicine price list (MPL) group.• For a complete list of chronic diseases covered, please check your member guide.

There is a specific Ruby, Emerald and Onyx (REO) Network which is made up of general practitioners (GPs) who have agreed to charge the Scheme rate and follow the managed care rules applicable to the GEMS Network relevant for these options.

You do not have to use the Network providers, but if you do, you can be assured that you will be using clinically appropriate and cost effective healthcare services.

All Network providers will display a GEMS Network logo/sticker in their practice window or door, making it easy for you to identify them.

Benefit check service • check your benefits to make them last

Friends of GEMS

Claiming made easy: frequently asked questions

Claim alert SMS

Get hospital pre-authorisation

How to apply for chronic medicine

A quick and easy way to check whether you have benefits available for any treatment you need is to use the SMS benefit check service. This service lets you know exactly what benefits you still have available for a specific benefit category. If you need to visit a doctor or to have a procedure done, you can check your available benefits by simply sending an SMS to 33489 (each SMS will cost you R1.50).

You can only use this service with the cellphone number on our records. Please make sure we have your current contact details so that you can use this convenient service.

You simply SMS: benefit, member number, keyword (in table below), dependant code and we will get back to you with your available benefits. A full guide to the benefit check service is available on the GEMS website at www.gems.gov.za.

Savings / PMSADay-to-day benefitAcute medicineChronic medicineAllied health servicesBasic dentistrySpecialised dentistryOptical benefitHospitalPMB

SaveDay

AcuteChronic

AlliedBasic

SpecialOptical

HospitalPMB

Keyword benefit category

Who can submit claims?Claims can be submitted by the member or the healthcare service provider.

How is a claim processed?The Claims Department receives the claim and assesses it according to the Scheme Rules. If the Scheme Rules allow, the claim will then be paid.

When are claims paid?Twice a month.

Are medicine claims processed immediately?Your pharmacy can send medicine claims to us electronically at the point of sale. The Scheme Rules will be applied immediately, so you will find out if GEMS will pay for the medicine right away. This means that you will get your medicine immediately, if you have available benefits, GEMS will pay for the medicine without you having to pay for it in cash.

How do I get a refund if I paid for a claim?If you have paid your healthcare service provider, please send your claim and proof of payment to GEMS as soon as possible. Refund payments to members are made electronically to the bank account that members have provided to the Scheme. You need to ensure that we have your accurate and up-to-date banking details.

What information must be included on a claim?When you submit a claim to GEMS, ensure that the following information is contained on the healthcare service provider’s invoice/claim:• Your member number, surname and initials;• The patient’s name and beneficiary code;• The Scheme name and your option;• The name and valid practice number of the healthcare service provider;• The date of service;• The nature and cost of treatment;• The pre-authorisation number, if applicable;• The tariff code and the relevant ICD-10 code;• Your signature to confirm that the account is valid; and• If you paid for the service, attach proof of payment.

How do I submit my claims?By post: All claims should be submitted to GEMS, Private Bag X782, Cape Town, 8000.By fax: 0861 00 4367By email: enquiries@gems.gov.zaBy hand: You can also deliver your claims to one of our regional offices.

Remember:Claims must be submitted to GEMS within four months from the date of service.

There are many advantages to visiting a GEMS Network GP:• You will not have to pay any out-of-pocket expenses for your consultations.• Your GEMS Network GP has agreed to provide excellent quality care to GEMS members at Scheme rates and not to charge you any co-payments or additional costs.• All GEMS Network GPs are willing to have their practice profiled (peer reviewed) and, where necessary, to accept guidance by their colleagues (peer mentoring) to improve their practice.• GPs who are profiled and achieve the highest status are rewarded with a higher consultation fee - at no additional cost to you, the GEMS member.

You can also find aFriend of GEMS online at

www.gems.gov.za

To receive

claim alert SMSs,

please call

0860 00 4367

Members can receive claim alert SMSs when GEMS processes their claims. The SMS acknowledges receipt of claims but is not a guarantee of payment. Ensure that you read your claim statements to see if your claim was paid or not. To receive claim alert SMSs, please call 0860 00 4367 and make sure that we have your current cellphone number.

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