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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.

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.
  • 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.

Dental

  • Members and dependants need authorisation from GEMS before they receive the following dental treatments: Any treatment in a private hospital or day hospital facility. Treatment under conscious sedation. Maxillo-facial surgery. Crown and bridge treatment. Periodontal treatment (also refer to Registering on the Periodontal Programme). Orthodontics. Plastic dentures (Tanzanite One and Beryl options). Implant-supported dentures, crowns and bridges. 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 treatments. The forms are available under “Forms“.
  • Any possible available orthodontic benefit in the following year will be used to pay for the remaining treatment in that benefit year only. 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 goes 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.
  • All denture-related claims for the Ruby, Emerald Value, Emerald and Onyx options are payable from the available shared dental sub-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 years.
  • If your application for pre-authorisation for a planned procedure has been declined, an appeal may be lodged at enquiries@gems.gov.za. The appeal process can take up to five working days before a decision is sent to you. Kindly await the outcome of the decision before proceeding with the treatment.
  • A treatment plan for orthodontic care is required, and approval is subject to prior evaluation according to the Index of Complexity, Outcome and Treatment Need (ICON) criteria. Your dental practitioner is familiar with the ICON criteria, and GEMS uses the records submitted by your dental practitioner to determine your orthodontic treatment needs. Fixed orthodontic treatment ranges from 9 to 36 months, depending on the complexity explained in the treatment plan. The approval for the orthodontic treatment plan is valid for one year. An updated authorisation is required annually for the remainder of the treatment. Members must please take note that should they change options, the benefits for the continued service may also change depending on the new option selected. Once orthodontic treatment has been approved, you will receive an authorisation letter that specifies the requested amount and the approved amount. If the dental benefit is depleted or the dental practitioner charges more than the Scheme rate, the member will be responsible for paying the difference.
  • More information on Dentistry and Maxillofacial Surgery Exclusions can be found in Annexure E of the GEMS Scheme Rules. Certain dental procedures have age limits and/or a restricted number of dental procedures allowed per beneficiary in each time period. Detailed information on these restrictions is shared with dental providers in the GEMS Dental Provider Guide.
  • When GEMS approves the treatment, it does not guarantee that GEMS will pay for the full treatment. Benefits are paid from the available shared dental sub-limit for the beneficiary at the time of processing the claim. The amount cannot be held in reserve. Once approved, GEMS will pay the provider an initial amount and the balance in monthly instalments, subject to the funds available from the beneficiary's shared dental sub-limit. Should a case be transferred to another provider, only the balance due as per the original treatment plan is covered. Valid claims will only be covered if the beneficiary’s GEMS membership is active and valid on the treatment date. When transferring to another provider, e.g. if the member has relocated or is seeking a second opinion, kindly request the records from the applicable provider to avoid a duplication of costs or possible overexposure to radiation from repeated X-rays.
  • Dental hospitalisation is only permitted for patients up to and including the age of six or for impacted teeth or severe trauma (PMBs). All procedures performed under general anaesthesia require pre-authorisation. You will be asleep throughout the procedure if you are given general anaesthesia. This is usually done in a hospital or a day theatre setting. For admission to a private facility (including facilities on the GEMS Hospital Network list and one-day admissions for elective procedures), please contact us at least 48 hours before your treatment to request pre-authorisation for hospitalisation. Unless it is an emergency, a co-payment of R1 000 per admission will apply if pre-authorisation is not obtained within 48 hours of the event. If a patient is admitted to a private facility for an emergency, the Scheme must be notified within one working day of the admission. Otherwise, a co-payment of R1 000 per admission will apply. If you are on the Tanzanite One or the Emerald Value Option, you are required to use a State or GEMS Network facility for admission; failing this, the Scheme shall not be liable to fund the first R15 000 of the non-network facility's bill. Use a GEMS Network facility to avoid any out-of-pocket expenses. You can view the list here or call 0860 00 4637.
  • The general recommendation is to go for a regular dental check-up and professional cleaning at least once every six months. Along with other good oral hygiene habits, regular dental visits will help prevent the development of tooth decay (caries) or gum disease. An oral healthcare practitioner is able to detect and treat early gum disease and tooth decay before it becomes more serious, saving you from unnecessary pain and discomfort.  
  • Your dental provider may inform you that your dental procedure will be performed under conscious sedation in certain circumstances and for specific procedures. Conscious sedation means that you are awake but relaxed during the procedure. This procedure is carried out in the dental chair, in the provider's consulting rooms. All procedures performed under conscious sedation require pre-authorisation. Benefits for treatment under conscious sedation in the dentist's rooms are available for patients up to and including the age of nine years or if they have impacted teeth, subject to pre-authorisation and managed care protocols.  For beneficiaries on Tanzanite One and the Beryl benefit option, the services must strictly be provided by a practitioner who is part of the GEMS dental network.
  • Dental fissure sealants are a simple and effective way to prevent tooth decay, and your GEMS dental benefits cover them. Managed care protocol apply for this treatment. You can enquire with your dentist, dental therapist or oral hygienist about fissure sealants for your child's permanent teeth.
  • Yes, GEMS covers dental fissure sealants, subject to managed care protocols. The Preventative Care Services benefit covers dental fissure sealants on the Ruby, Emerald Value, Emerald, and Onyx options if they are obtained from a network provider and not from the shared dental sub-limit. This benefit enhancement applies to beneficiaries younger than 18 years of age who use dental network providers only. Should beneficiaries receive this treatment from a non-network provider, the treatment will be paid from the available shared dental sub-limit, not the Preventative Care Services benefit.
  • 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. Such services must be provided by a dentist who is part of the GEMS dental network for the claim to be payable. This benefit is subject to the available shared dental sub-limit for all other options. This means that the claim will be paid if there are available benefits. Otherwise, this will likely be a shortfall to be funded by the member.
  • 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, the use of a GEMS dental network provider, and is limited to the approved Scheme tariff. No benefit is available for metal frame dentures.
  • You can find a list of GEMS dental network providers for your option here or by calling 0860 00 4367. Choose option 4, your preferred language, then option 2 for Dental and option 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. See also “Why is it a good idea to use the GEMS dental network?”.  
  • Avoid sugary foods and sugar-filled drinks. Brush your teeth with fluoride toothpaste for two minutes every morning and every night. Floss every day to clean between your teeth. Make it a habit to rinse your mouth with water after every meal. Keep to your regular dental visits. Enquire with your dentist, dental therapist or oral hygienist about dental fissure sealants for your child’s permanent teeth.
  • GEMS recommends that you visit your dentist or dental therapist every six months for a dental check-up and oral preventative care. Please consider visiting a dental provider who is a member of the GEMS dental network to avoid unexpected out-of-pocket expenses. GEMS dental network providers charge the agreed-upon Scheme tariffs, while non-network providers may charge above the Scheme rate. GEMS will only pay up to a certain limit for each service; thus, a shortfall may then be for you to pay to the provider directly. You may not have to pay any out-of-pocket expense at a network provider if the Scheme covers the service rendered and you have benefits available for the treatment. If any dental work is required that is not covered by GEMS, the network provider will need to obtain your permission before proceeding with the treatment. This should include a cost discussion between yourself and the provider. This way, you will always know what dental bills to expect. If you are on Tanzanite One or the Beryl option, your dental services must be provided by a dentist, dental therapist, or oral hygienist who is part of the GEMS dental network, in line with the Scheme Rule expectation. You can find a network provider for your option here or by calling 0860 00 4367. Choose option 4, your preferred language, then option 2 for Dental and option 3 for General Enquiries
  • When you visit a dental provider in the GEMS Network, the practice should not charge more than the agreed-upon Scheme tariffs. You should inform GEMS if 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 GEMS at 086 000 4367 to lodge a complaint. Choose option 4, your preferred language, then 2 for Dental enquiries and 3 for General Enquiries.  
  • To be eligible for periodontal treatment benefits, members on the Tanzanite One and Beryl options must be enrolled by their GEMS dental network provider on the Periodontal Programme. Your GEMS dental network provider must complete the periodontal pre-authorisation form and forward it to GEMS, together with the supporting documentation, to enquiries@gems.gov.za or fax to 086 100 4367. The form explains to the provider all the requirements for registration. The “Periodontal” form is available under Forms.
  • Periodontal (gum) disease treatment is limited to local anaesthesia, with no coverage for in-hospital care. To be eligible for periodontal treatment benefits, Tanzanite One and Beryl members must be enrolled by their GEMS dental network provider on the Periodontal Programme. The Periodontal Programme is a Disease Management programme for patients with mild periodontitis. Once the treatment plan is approved for out-of-hospital care, the enhanced benefits for dental cleaning and specialised treatment (such as root planing) will help prevent tooth loss. 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.
  • Benefits on the Tanzanite One and Beryl options are subject to the use of a GEMS dental Network provider. Members are allowed one emergency out-of-network visit per year for pain and sepsis treatment. If there is no network provider in your area, call GEMS at 0860 00 4367 before going to the dentist or dental therapist to see if the visit is covered. This will help you avoid unexpected shortfalls when the claim is received at GEMS. Choose option 4, your preferred language, then option 2 for Dental enquiries and option 3 for General Enquiries.
  • The benefit for orthodontic treatment is available to GEMS beneficiaries under the age of 21 on the Ruby, Emerald Value, Emerald and Onyx options only. GEMS does not have a separate benefit limit for orthodontic treatment. This means that all orthodontic claims are payable from the available shared dental sub-limit. Orthodontic treatment is a once-in-a-lifetime benefit per beneficiary, and retreatment is not funded. Valid claims will only be covered if the beneficiary's GEMS membership is active and valid on the treatment date.