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  • General
  • FAQs
  • Dental
  • Hospital
  • Medicine

General

  • Emergency medical response by road or air to the scene of a medical emergency; Transfer by road or air to the closest, most appropriate medical facility; and Repatriation of a patient where medical intervention is required. Only dial 0800 44 4367; Give your name and the telephone number that you are calling from; Provide a brief description of what has happened and how serious the situation is; Give the address or location of the incident to assist paramedics to get there; Do not put down the phone until the person on the other side has disconnected. Important points to remember: - Please ensure that all your registered dependants are aware of this service. - Inform your child's school that he/she is a member of GEMS. Make sure your child and the school know the emergency medical service number.
  • Members must phone 0800 44 4367 in all medical emergencies.
  • Chronic medicine is medicine used on an ongoing basis to treat disabling and/or potentially life-threatening chronic (long-lasting) illnesses, like diabetes, that have a negative effect on your health and quality of life. Chronic medicine must be pre-authorised by the Medicine Management Department to ensure appropriateness and cost effectiveness. Some medicines are not paid in full if they are not on the Scheme's formulary or Medicine Price List (MPL). Always check with your doctor to see if the most cost effective medicine is prescribed according to the MPL and the formulary so that you do not need to pay out of your own pocket.
  • Please ensure that your doctor, the hospital case manager or a family member informs GEMS of the extended length of stay on 0860 00 4367. If there is a valid clinical reason for the stay, GEMS will approve the extra days.  
  • You need to supply your Chronic Medicine pharmacy (either the Courier Pharmacy or GEMS Network pharmacy) with a valid doctor's prescription before they can supply you with your chronic medicine. Prescriptions have to be renewed every 6 months this is a legal requirement . A repeat prescription is valid for not more than the repeats specified on the Medicine Access Card and will be effective from the date written on the prescription. A prescription cannot be repeated for more than six months. The Chronic Medicine Manager will send you an SMS to remind you to obtain a new prescription before your old one runs out . Whether you are obtaining your medicine from the Courier Pharmacy or GEMS Network Pharmacy, you will need to send a new prescription when this is due. Your chosen Pharmacy will not send or provide you with medicine if your prescription has expired
  • GEMS is a legal entity separate from the employer and is governed by a Board of Trustees. In other words, the Board of Trustees determines the rules under which the Scheme operates, including benefits and contributions. The employer on the other hand determines the conditions of service of employees through negotiations with trade unions. In determining the conditions of service of public service employees, the employer may for example determine whether or not its employees are compelled to belong to one scheme or whether the employees have total freedom of choice of scheme. The employer also determines what level of subsidies will apply to different categories of employees or in general. Employers also play an important role in collecting contributions and ensure payment thereof to the scheme concerned.
  • If a visit or admission to a hospital (out-patient or in-patient), or any scan is planned, please let us know 48 hours before the event. In the event of emergency treatment or admission to hospital over a weekend, public holiday or at night you MUST contact the Call Centre on the first working day after the incident. If you fail to get pre-authorization for a planned event or authorization on the first working day after an emergency event you will be liable to pay a R1 000 penalty.
  • GEMS pays for in-hospital allied health services if it is clinically indicated and provided that it is authorised in addition to your hospital admission. The hospital case manager, Allied Health Practitioner or your doctor will contact GEMS to request this authorisation and send all the necessary information..

FAQs

  • click here for more information
  • The allied healthcare provider must obtain a written referral from the admitting/treating doctor, indicating the need for the requested services. Note that an authorization for the admitting/treating provider must be on the system already when a pre-authorization for an allied health provider is requested. The letter of referral must be submitted to enquiries@gems.gov.za for consideration in accordance with the relevant managed care protocols and Scheme rules. If the service is deemed appropriate, written pre-authorisation will be communicated to the healthcare provider; and when submitting the claim to the Scheme, both the referring doctor’s practice number and the pre-authorisation number if issued must be reflected thereon.

Dental

  • Hospitalisation and dental treatment under general anaesthetic / in theatre is allowed only for the removal of impacted teeth, severe trauma (PMBs) or patients younger than six years.  To request pre-authorisation, ask your dental service provider to complete and submit the Dental Report form which is available under Forms on the GEMS Information Centre page. Periodontal treatment in hospital is not covered.   
  • All denture-related claims for the Ruby, Emerald, Emerald Value and Onyx options are payable from the available shared dentistry limit at 100% of the Scheme rate. Members are allowed one set of plastic dentures per beneficiary every four years, with rebase and relines of the soft base every two years. Metal frames for partial dentures are limited to one per jaw, once every five year.
  • The GEMS dental benefit for Tanzanite One and Beryl members allows for one set of plastic dentures per beneficiary every four years. Only members and beneficiaries over the age of 21 qualify for this benefit. The benefit is subject to pre-authorisation, use of a GEMS Dental Network Provider and limited to the approved Scheme tariff. No benefit available for metal frame dentures.
  • Root canal treatment is covered on all options.  For Beryl and Tanzanite One members, this benefit is limited to one root canal treatment per beneficiary per year, and services must be provided by a dentist who is part of the GEMS dental network.  For all other options, this benefit is subject to the annual limit for out-of-hospital dental services.  Refer to the Dental Benefit section in the GEMS Member guide for more information on treatment covered: /Information/Member-Guides.  
  • Benefit for orthodontic treatment is only available to GEMS beneficiaries under the age of 21 on the Ruby, Emerald, Emerald Value and Onyx options. This is a once in a lifetime benefit per beneficiary. GEMS does not have a separate benefit limit for orthodontic treatment; all claims are payable from the available dental financial limit.   
  • Find your GEMS option on the Home page, click on “Learn more” and then “View Network Doctors”. You can search for a dental practice by province and practice type i.e.,  a dentist, dental therapist, oral hygienist, or maxillo-facial and oral surgeon.  The following links will take you directly to the search page for your option: • Tanzanite One and Beryl options • Ruby, Emerald Value, Emerald and Onyx options Alternatively, phone the GEMS contact centre on 086 000 4367 for assistance. Choose option 4; your preferred language; then 2 for Dental and 3 for General Enquiries.  All GEMS network providers will display a GEMS Network sticker on their practice window or door, making it easier for you to identify them. Before you make a dental appointment, always confirm with the practice if they are a GEMS Dental Network provider for your specific option.  
  • To register you on the programme, you GEMS Dental Network Provider must complete and submit to GEMS the periodontal pre-authorisation and programme registration form.  The form explains to the provider all the requirements for registration.  The periodontal form is available under Forms on the GEMS Information Centre page.  
  • Any possible available orthodontic benefit in the following year, will only be used to pay for the remaining treatment in that benefit year. So please make sure that you have enough personal funds available to continue orthodontic treatment and routine dental treatment when benefits get depleted. Your dental practitioner will plan regular appointments to monitor the movement and to make sure that everything is going according to plan. If you miss appointments, over- or under-correction can occur, which means more time before you can say goodbye to the retainers.  
  • • Avoid sugary foods. • Brush your teeth twice a day. • Floss every day. • Visit your dentist or dental therapist regularly. • Ask your dentist or dental therapist for fissure sealants on your children’s permanent teeth.  
  • Members and dependants need authorisation from GEMS before they receive the following dental treatment:  • Treatment under sedation or conscious sedation, • Dental hospitalisation,  • Maxillo-facial surgery,  • Crown and bridge treatment,  • Periodontal treatment,  • Orthodontic treatment and  • Plastic dentures (Tanzanite One and Beryl options).  To request pre-authorisation, ask your dental service provider to complete and submit the Periodontal form (for Periodontal treatment) or the Dental Report form (for all other treatment).  The forms are available under “Forms” on the GEMS Information Centre page.  
  • When GEMS approves the treatment, it does not guarantee that GEMS will pay for the treatment. Benefits are only paid from the available dental financial limit for the beneficiary at the time of processing the claim. The amount cannot be held in reserve. Approved treatment plans are valid for one year. An updated authorisation is required on an annual basis for the remainder of the treatment. Once the application for orthodontic treatment has been approved, you will receive an authorisation letter that specifies the requested amount, as well as the approved amount. If the dental benefit is depleted, or if the dental practitioner charges more than the Scheme rate, the member will be responsible for paying the difference.  Ex gratia assistance is available should you qualify. Kindly await the outcome of the decision before proceeding with treatment. Ex gratia assistance is available should you qualify. Kindly await the outcome of the decision before proceeding with treatment. The Ex Gratia process is explained on the Ex Gratia application form which is available for download under “Forms” on the GEMS Information Centre page.  
  • Although benefits payable on the Tanzanite One and Beryl options are subject to the use of a dental provider on the GEMS Dental Network, members are allowed one emergency out-of-network visit per year. This is only applicable to emergency pain and sepsis treatment.  If there is no network provider in your area, contact GEMS on 086 000 4367 before you go for treatment to confirm if the visit will be covered. Choose option 4; your preferred language; then 2 for Dental and 3 for General Enquiries. This will help you avoid unexpected co-payments.   
  • The Periodontal Programme is a GEMS initiative that allows the Tanzanite One and Beryl members who suffer from advanced gum disease, access to extra benefits.  Once the members are successfully registered on the Periodontal Programme, they qualify for the enhanced benefits for dental cleaning and periodontal treatment (i.e., root planing). These extra benefits are only available if the treatment is provided by a dentist, dental therapist or oral hygienist who is part of the GEMS Dental Network. Periodontal treatment in hospital is not covered.   
  • When you visit a dental provider in the GEMS Network, the practice should not charge you more than agreed with the Scheme. Inform GEMS when the network provider asks you to pay an administration fee or holds you liable for charges above the GEMS dental tariff. This can be done by calling the contact centre on 086 000 4367 to lodge a complaint. Choose option 4; your preferred language; then 2 for Dental and 3 for General Enquiries. 
  • A visit to the dentist or dental therapist every six months, along with other habits for good oral hygiene, will prevent the development of tooth decay (caries) or gum disease.  When detected at an early stage, gum disease is treatable with minimal intervention. Early detection and treatment will also decrease pain and discomfort. The dental practitioner is trained to look after your teeth and mouth.   

Hospital

  • If your chronic medicine changes in any way, GEMS needs to be advised. The quickest way is for the prescribing doctor or dispensing pharmacist to contact the clinical staff on the Service Provider Line (0860 436 777). The change is processed within 5 days . An updated Medicine Access Card will be mailed to you for your records. You will need to provide your Chronic Courier or the GEMS Network pharmacy (where you are registered) with the new prescription so that the medicine can be dispensed. It is not necessary to request a new Medicine Access Card if the authorized product is replaced by a generic equivalent within the same Medicine Price List (MPL) group.
  • GEMS has an Emergency Medical Services (EMS) provider network that provides unlimited emergency medical assistance to GEMS members. Dial 0800 44 4367 to contact the Emergency Medical Evacuation Dispatch (EMED) centre. You will be asked for information to facilitate the allocation of an appropriate EMS provider. This service is available 24 hours a day and 7 days a week.
  • A visit or admission to a hospital (out-patient or in-patient), or any scan requires authorisation, please contact GEMS 48 hours before the event. In the event of emergency treatment or admission to hospital over a weekend, public holiday, or at night, you should contact the Call Centre on the first working day after the incident. If you fail to get pre-authorisation for a planned event or authorisation on the first working day after an emergency event, you will be liable to pay a R1 000 penalty.
  • GEMS will need to approve additional days that you need to remain in hospital. The hospital case manager or your doctor will send clinical updates to GEMS and request approval for the additional days. GEMS will approve the extra days if there are valid clinical reasons.
  • GEMS has an Emergency Medical Services (EMS) provider network that provides unlimited emergency medical assistance to GEMS members. Dial 0800 44 4367 to contact the Emergency Medical Evacuation Dispatch (EMED) centre. You will be asked for information to facilitate the allocation of an appropriate EMS provider. This service is available 24 hours a day and 7 days a week.
  • If you need to be transferred from one hospital facility to another, please inform the hospital that you are a GEMS member and that any inter-hospital transfers must be authorised by the Scheme. The hospital needs to call the EMED centre on 0800 44 4367 for more information.
  • No, pre-authorisation is only required for physiotherapy while you are admitted to hospital. Any physiotherapy out-of-hospital will be funded from your available benefits..

Medicine

  • Yes, you can appeal the decision to either reject your application for chronic medicine or to provide you with alternative medicine to the medicine your doctor prescribed. To appeal you must ask your doctor to write a clinical motivation and email it to chronicdsp@gems.gov.za. Your doctor can also call us on 0860 436 777. The clinical motivation will be considered carefully by the medical adviser; however, this does not mean your appeal will be successful.
  • Chronic medicine is medicine used on an ongoing basis to treat disabling and/or potentially life-threatening chronic (long-lasting) illnesses, like diabetes, that have a negative effect on your health and quality of life. Chronic medicine must be pre-authorised by the Medicine Management Department to ensure appropriateness and cost effectiveness. Some medicines are not paid in full if they are not on the Scheme's formulary or Medicine Price List (MPL). Always check with your doctor to see if the most cost effective medicine is prescribed according to the MPL and the formulary so that you do not need to pay out of your own pocket.
  • You can apply for an advance supply of chronic medicine if you need more medicine than the amount that is normally dispensed, particularly if you are travelling outside the borders of South Africa on vacation or for work. The minimum amount of advance medicine supply you can request should be equivalent to one month's stock. When applying for an advance supply of medicine, you are required to: Obtain an Acknowledgment of Debt Form by contacting GEMS or visiting the website. . Complete the form for each beneficiary requesting an advance supply and submit it via email to enquiries@gems.gov.za or fax to 0861 00 4367. Attach the following documents to the request: Flight itinerary or a letter confirming the departure and return dates as well as a travel plan All relevant documents if using other modes of transport Prescription, if your current prescription will expire while you are still away Employment contract, if working abroad Date on which you will collect the medicine from your allocated pharmacy or the date on which you would like the Courier Pharmacy to deliver. GEMS will notify you if your advanced medicine supply request has been approved or provide reasons if it has been declined.
  • Call GEMS on 0860 00 4367 and ask for a Chronic Medicine Application Form or download one from the GEMS website at www.gems.gov.za(Click on 'Forms' under 'Members') . Your treating doctor must complete the form A separate form must be completed for each member or dependent who needs chronic medicine. You only need to complete this application form once . Ensure that your application form is completed in full . Ensure that both you and your doctor have signed the application form. . Fax the completed form to 0861 00 4367 or Email your form at chronicdsp@gems.gov.za. We will then review your application. We will check it against the Scheme Rules to see if we can cover the medicine under the chronic medicine benefit . If we approve your application, you will receive a Medicine Access Card, listing the medicine that we have agreed to pay for from your chronic medicine benefit . If the medicine that we have agreed to pay for differs from the medicine your doctor has prescribed, we will attach a letter to your Medicine Access Card that will explain the reasons for this. We will also send a copy of the letter to the doctor who prescribed the medicine . If we do not approve your application for chronic medicine, you and your doctor will both receive a letter explaining this decision
  • If your medicine authorisation request has been declined, a letter will be sent to you and a copy will be sent to your prescribing doctor. If further clinical information is required, your request will be reconsidered once all the relevant information has been received from your doctor. Your doctor may call 0860 436 777 for assistance.
  • You can apply for an emergency (urgent) supply of medicine if: You are a new beneficiary on the Chronic Medicine Management Programme (CMMP) and you need your medicine to be authorised urgently. You are an existing beneficiary on the CMMP and require an urgent supply of medicine for a new condition, or for new or changed medicine. Obtain the Chronic Medicine Application Form by contacting GEMS or visiting the website (request your healthcare provider to complete the form on your behalf). Send the completed form via email to chronicdsp@gems.gov.za or fax to 0861 00 4367. If you want to update your chronic medicine on an existing authorisation, request your healthcare provider to phone GEMS Chronic Authorisations to change the medicine. Send the new prescription via email to enquiries@gems.gov.za or fax to 0861 00 4367. When applying for emergency medicine, you are required to: New members Obtain the Chronic Medicine Application Form by contacting GEMS or visiting the website (request your healthcare provider to complete the form on your behalf) Send the completed form via email to chronicdsp@gems.gov.za or fax to 0861 00 4367. Existing members If you want to update your chronic medicine on an existing authorisation, request your healthcare provider to phone GEMS Chronic Authorisations to change the medicine Send the new prescription via email to enquiries@gems.gov.za or fax to 0861 00 4367. GEMS will contact you once all the documents have been received.
  • 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 then they will contact you to make medicine delivery arrangements. If you choose to obtain your approved chronic medicine from a supplier that is not a GEMS Chronic Courier or Network pharmacy, you will be liable for a 30% co-payment, which must be paid directly to the pharmacy or dispensing doctor. Please note that the duration of authorization varies from medicine to medicine - some medicines may be authorized on an ongoing basis, whilst others may only be authorized for a limited period. The Medicine Access Card will indicate the duration for which the medicine has been approved.
  • No need to complete a physical form - simply call our dedicated call centre agents to help you with a telephonic chronic medicine registration. CALL the GEMS service provider call centre on 0860 436 777, press 4 for enquiries on chronic medicine, then 3 for enquiries on authorisation of chronic medicine. Have your practice number handy. EMAIL the prescription to chronicdsp@gems.gov.za to enable a courier pharmacy to dispense medication for members who choose to have the medication delivered. GEMS will also remind the members to renew the prescription before it expires.
  • Risk Management Responses (RMRs) assist healthcare providers in making informed financial and clinical risk management decisions at the point of service. These response messages are passed back to the provider as part of an electronic claim submission response. Top 5 RMRs (Claim Responses) and Explanations RMR Code RMR Description Comment Meaning Error Result Flag 553 Item processed as PMB Information The message specifies the PMB benefit that the claim/script was paid from. Warning 469 Submitted Gross Used Information The message confirms the Submitted Gross amount has been accepted and processed. Warning 7208 MPL Reference Price Exceeded Call to Action The dispensed product price is above the MPL reference price, and the member will incur a co-payment. Action to take, the provider is to consider an alternative within or below the MPL price. Warning 989 Price Difference on submitted Gross Call to Action The professional fee submitted for the product is above the contractually agreed amount and the difference will be a co-payment to the member. Action to take, the provider to comply with the contractual obligation. Warning 250 Out of formulary item Call to Action The dispensed product is outside the formulary list and the member will incur a co-payment. Action to take, provider to consider an alternative within the formulary. Warning
  • Administration fees (tariff code 0022) that are submitted alone without an accompanying vaccine NAPPI code will be rejected. A warning message of “admin fee was not submitted’ will be generated to remind providers if a vaccine NAPPI claim is submitted without an admin fee tariff code. 
  • GEMS applies a 'disease authorisation' to approve medicines for the treatment of chronic conditions, not just for a medicine. The disease authorisation provides access to a list of pre-approved medicines, referred to as a basket. Where a patient is already registered on the chronic medicine programme for a specific chronic condition, and the prescription is amended, the patient may present the prescription to the pharmacists to first submit the claim for the medication. Based on the real-time feedback received, the claim will either be processed successfully from the basket, or the pharmacist will be advised that pre-authorisation is required
  • GEMS covers medication prescribed by a registered PCDT pharmacist including the associated dispensing fee for medicines. Pharmacies must utilise the correct legislated ICD10 codes.
  • GEMS offers all members screening and preventative care benefits which are claimed from the risk benefit. Please refer to the GEMS Website for the list of available screening and preventative services or contact our Call Centre.
  • All pharmacies on the GEMS Network are measured on four (4) compliance measures, namely: Medicine Price List (MPL) Generic Substitution (GS) Dispensing Fee (DF) ICD-10 codes (OTC items only) Pharmacies compliance reports are distributed monthly, to ensure they can track performance against target. Pharmacies that are having challenges with meeting the compliance scores can request for engagements with the PNMP Provider Liaison Officers or compliance pharmacists, who will assist them on how to reach the mandated compliance scores.
  • As an FP, you can assist your patients who are GEMS members to avoid undesirable co-payments by ensuring that all scripted items are within the Acute/Chronic Formularies, and by encouraging members to make use of DSP pharmacies. More about co-payments: There are three types of co-payments: In order to contain the escalating costs of medicines, GEMS uses the MPL to determine the maximum price the Scheme will pay for those medicines with the same active ingredient based on the availability of generic equivalents on the market. The fundamental principle of the MPL is that it does not restrict a member’s choice of medicines, but instead limits the amount that will be paid should a member choose a medicine above the MPL. MPL reference prices are carefully determined so as to ensure adequate availability of generic equivalents within the price limit, without co-payments being necessary. (GEMS is also encouraging the use of reusable insulin pens and cartridges for diabetic members on insulin.) If a member uses a product that costs more than the MPL reference price, the member will attract an MPL co-payment. In addition, GEMS makes use of formularies for acute and chronic medicine, which are available on the website. Out-of-formulary co-payments are incurred when members use non-formulary drugs or medicine that is charged above the MPL reference price.  Finally, claims submitted from a non-DSP pharmacy will also attract a 30% non-DSP co-payment.
  • By using GEMS Designated Service Providers (DSPs) to avoid a 30% co-payment. Choosing medicine that is in the GEMS formulary, which is a cost-effective generic, and matches the reference price in the GEMS Medicine Price List (MPL).
  • This formulary is a list of cost-effective chronic medicine that GEMS pays in full according to Scheme Rules. If your doctor prescribes chronic medicine that is not in the GEMS formulary, you will have to pay a 30% out-of-formulary co-payment. Please click here for the GEMS medicine formulary list.
  • GEMS DSPs are all the courier pharmacies as well as pharmacies that are on the GEMS Network. Please click here for the list of the GEMS network pharmacies.
  • A co-payment is a portion of the cost of medicine which you as a member must pay out of your own pocket. It can be a certain amount or a percentage of the total bill.
  • GEMS uses a medicine reference pricing tool called the Medicine Price List (MPL) to set the maximum price that the Scheme will pay for certain groups of generically similar medicines. Where a member or service provider chooses medicine that costs more than the reference price indicated on the MPL, the member will pay the difference between the reference price and the actual cost. Ask your pharmacist to supply generic medicine within the MPL where possible, so that you avoid paying MPL co-payments.
  • Generic medicines are safe, registered medicines that contain the same active ingredients as the original or branded medicines and achieve the same therapeutic results at a lower cost.
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