2019 Benefit Schedule

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Benefit Schedule Glossary
ACDL: Additional Chronic Disease List. A list of chronic diseases the Scheme covers in addition to the CDL.
Benefit option: Each of the six GEMS benefit options – Sapphire, Beryl, Ruby, Emerald Value, Emerald and Onyx – have a different cost and range of
healthcare benefits.
Benefit schedule: A list of the benefits provided by each benefit option.
CDL: Chronic Disease List. The 26 specific chronic diseases the Scheme provides a minimum level of cover for, as required by Law.
CT and MRI scans: Special X-rays taken of the inside of your body to try to find the cause of a medical condition.
DMP: Disease Management Programme. Specific care programmes to help members manage various chronic conditions.
DSP: Designated Service Provider. The Scheme has an agreement with certain healthcare providers to provide specific services to members at agreed rates.
DTP: Diagnosis and Treatment Pairs. The 270 PMBs in the Medical Schemes Act linked to the broad treatment for specific conditions.
GP: General Practitioner. A doctor based in the community who treats patients with minor or chronic illnesses and refers those with serious conditions to a hospital.
MEL: Medicine Exclusion List. Medicine that is excluded from benefits in terms of the Scheme rules.
MPL: Medicine Price List. A reference GEMS uses to calculate the prices of groups of medicine.
Pre-authorisation (PAR): The process of informing GEMS of a planned procedure before the event so that the Scheme can assess whether benefits will be granted.
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.
PDF: Professional Dispensing Fee. A maximum fee that a pharmacist or dispensing doctor may charge for their services, as determined by South African law.
PMSA: Personal Medical Savings Account. The portion of your monthly contribution allocated to a savings account to pay for your out-of-hospital medical expenses.
The PMSA is only applicable to the Ruby Option.
PMBs: Prescribed Minimum Benefits. Basic benefits that GEMS provides for certain medical conditions. GEMS, like all other medical schemes in South Africa, must offer
these benefits according to the law.
Scheme rate: The price agreed by the Scheme to pay for healthcare services that service providers give to members of the Scheme.
SEP: Single Exit Price. The one price that a medicine manufacturer or importer charges for medicine to all its customers, as determined by South African law.
TTO: Treatment Taken Out. The medicine you receive when you are discharged from hospital. Usually lasts for seven days.
 Emerald In-Hospital Benefits KEY: 1 Pre-authorisation is needed 1 100% of Scheme rate 1 100% of cost, subject to PMB legislation 1 Subject to managed care rules
1 Limited to PMBs 1 Subject to the service being related to admissions under the annual hospital benefit

Prescribed minimum benefits (PMBs) – Unlimited, subject to PMB legislation • Service provided by DSP • PMBs override all other benefit limitations 11 11
Annual hospital benefit (public and private hospitals, registered unattached theatres, day clinics and psychiatric facilities) – Unlimited • Services rendered by DSP • Includes accommodation in a general ward, high-care ward and intensive care unit (ICU), theatre
fees, medicines, materials and hospital equipment (including bone cement for prostheses) and neonatal care • Accommodation in private ward is subject to motivation by attending practitioner • Co-payment of R1 000 per admission if pre-authorisation not obtained 1 11
Alcohol and drug dependencies – Subject to pre-authorisation and managed care 1 111
Allied health services – Includes dieticians, social workers, orthoptists, physiotherapists • Shared with out-of-hospital limit of R1 599 per family per year • Sub-limit of R800 per family for social workers and registered counsellors • Subject to managed care protocols and
services being related to admission diagnosis 1 1
Alternatives to hospitalisation (sub-acute hospitals and private nursing) – Includes home nursing • Excludes frail care and recuperative holidays • Includes physical rehabilitation for approved conditions and home nursing • Hospice • Unlimited, subject to PMB
legislation 11 111
Blood transfusion – Unlimited, subject to PMB legislation • Includes cost of blood, blood equivalents, blood products and transport thereof • Includes erythropoietin 11 11
Dental services (conservative, restorative and specialised) – Only applicable to beneficiaries with severe trauma, impacted third molars or children under the age of 6 years • Subject to list of approved services and use of day theatres within the network • Shared with
out-of-hospital dental services • Limited to R5 184 per beneficiary per year • General anaesthesia and conscious sedation subject to managed care protocols and processes • Excludes osseo-integrated implants, all implant-related procedures and orthognathic surgery
111
Emergency services (casualty department) – Subject to use of facility as per in-hospital benefits or other registered emergency facility • Paid from out-of-hospital GP services if pre-authorisation is not obtained 111
GP and Specialist services – Unlimited • Reimbursement according to Scheme-approved tariff rate • 100% of Scheme rate for non-network specialists • 130% of Scheme rate for network specialists
Mental health – Accommodation, theatre fees, medicine, hospital equipment, professional fees from GPs, Psychiatrists and Psychologists • Limited to R18 592 per family per year • Limited to 1 individual psychologist consultation and 1 group psychologist consultation per
day • Maximum of 3 days’ hospitalisation by GP • GP nomination rules apply • Educational and industrial psychologists excluded • All limits are subject to PMBs 111 1
Oncology (chemo and radiotherapy) – In and out of hospital • Includes medicine and materials • Limited to R371 852 per family per year • Sub-limit of 252 964 per family per year for biological and similar specialised medicine • Includes cost of pathology, radiology,
medical technologist and oncology medicine • Subject to MPL • Erythropoietin included in blood transfusion benefit • Subject to PMBs 1 11 1
Organ and tissue transplants – Includes materials • Limited to R619 748 per beneficiary per year • Limit includes all costs associated with transplant including immuno-suppressants • Sub-limit of R21 038 per beneficiary per year for corneal grafts (imported corneal
grafts subject to managed care rules) • Authorised erythropoietin included in blood transfusion benefit • Organ harvesting limited to South Africa, except for corneal tissue 111 1
Pathology and Medical Technology – Unlimited • Subject to pathology tests being related to admission diagnosis 1 111
Physiotherapy – Limited to R5 014 per beneficiary per year • 10 post-surgery physiotherapy visits for post-hip, knee and shoulder replacement or revision surgery (shared with out-of-hospital visits) up to a limit of R5 292 per beneficiary per event used within 60 days of
surgery 11 11
Medical and surgical appliances and prostheses – Benefit of R42 171 per family per year shared with medical and surgical appliances as well as external prostheses • Shared sub-limit with out-of-hospital prosthetics and appliances of R4 631 for foot orthotics and
prosthetics • Sub-limit of R1 323 for orthotic shoes, foot inserts and levellers per beneficiary per year • R527 for crutches per beneficiary per year • R5 797 for wheelchairs per beneficiary per year • R8 432 per hearing aid per beneficiary per year • One CPAP device of up
to R10 013 per beneficiary every 36 months • Subject to PMBs 1 11 1
Radiology (advanced) – Shared with out-of-hospital advanced radiology limit of R22 309 per family per year • Specific authorisation in addition to hospital pre-authorisation required 11 11
Radiology (basic) – Unlimited • Includes 2 x 2D ultrasound scans per pregnancy. Should a 2D scan be substituted with a 3D or 4D scan, it will be funded up to the cost of a 2D scan 1 1
Renal dialysis – In hospital • Includes materials and related pathology tests • Includes cost of radiology, medical technologists, material and immuno-suppressants • Includes related pathology tests done at network provider • Limited to R265 601 per beneficiary per year
for chronic dialysis • Acute dialysis included in the in-hospital benefit • Erythropoietin included in blood transfusion benefit • Pathology and radiology test subject to managed care 1 111
Surgical procedures (including maxillofacial surgery) – Unlimited • Excludes osseo-integrated implants, all implant-related procedures and orthognathic surgery • Includes hospital procedures performed in practitioners’ rooms 111
 Emerald Out-of-Hospital Benefits KEY: 1 Pre-authorisation is needed 1 100% of Scheme rate 1 100% of cost, subject to PMB legislation 1 Subject to managed care rules
1 Limited to PMBs 1 Subject to the service being related to admissions under the annual hospital benefit

Personal Medical Savings Account (PMSA) – No PMSA

Allied health services – Subject to block benefit (day-to-day benefits) • Includes dieticians, social workers, orthoptists, physiotherapists • Shared with in-hospital allied health services limit of R1 599 per family per year • Sub-limit of R800 per family for social workers and
registered counsellors 1 111
Audiology, occupational therapy and speech therapy – Subject to day-to-day block benefit • Occupational or speech therapy performed in-hospital will be paid from the in-hospital benefit • Shared limit of R2 263 per beneficiary per year and R4 534 per family per year
shared with pathology and medical technology • Sub-limit of R1 819 per beneficiary and R3 636 per family per year
Block benefit (day-to-day benefit) – Out-of-hospital GP and specialist services, physiotherapy, maternity (where not covered under the Maternity Programme), audiology, occupational therapy, speech therapy, pathology and medical technology • Limited to R4 634 per
beneficiary and R9 279 per family per year • Benefit is pro-rated from join date 1
Chronic Back and Neck Rehabilitation Programme – Subject to the use of DSP, managed care protocols and processes 11
Circumcision – Global fee of R1 498 per beneficiary, which includes all related costs of post-procedure care within month of procedure • Out of hospital only 1 1 1
Contraceptives (oral, insertables, injectables and dermal) – Subject to formulary • Subject to acute medicine benefit limit • Sub-limit of R2 822 per beneficiary per year 11
Dental services (conservative, dentistry including acute medicine) – Shared with in-hospital dentistry sub-limit of R5 184 per beneficiary per year • Plastic dentures included • General anaesthesia and conscious sedation require pre-authorisation and are subject to
managed care protocols • Only applicable to beneficiaries with severe trauma, impacted third molars or under the age of 8 years • 200% of Scheme rate for treatment of bony impactions of third molars under conscious sedation in doctors’ rooms • Panoramic X-rays
limited to 1 X-ray every 3 years per beneficiary • 4 bitewing X-rays per beneficiary per year • Fluoride treatment excluded for beneficiaries older than 16 years • Specialised dentistry – No pre-authorisation required for metal base partial dentures 111
Emergency assistance (road and air) – Unlimited, subject to PMB legislation • Subject to use of emergency services DSP 1 11
General Practitioner (GP) and Specialist services – Subject to day-to-day block benefit • GP visits limited to R4 638 per beneficiary and R9 279 per family per year • Reimbursement at 200% of Scheme rate for procedures specified by managed care done in specialist’s
rooms instead of in hospital • Reimbursement at 200% of Scheme rate for cataract procedures performed by ophthalmologists in their rooms 111 1
GP network extender benefit – For beneficiaries with chronic conditions registered on disease management programme • 2 additional GP consultations at a network GP once block benefit is exhausted • Payable from risk 11 1
HIV infection, AIDS and related illness – Subject to registration on the HIV Disease Management Programme 111
Infertility – Subject to use of DSP • Subject to PMBs and managed care protocols 1111
Maternity (ante- and post-natal care) – 100% of Scheme rate paid from risk, if registered on Maternity Programme • Subject to: Maternity Programme protocols, managed care protocols and processes and PMBs OR 100% of Scheme rate paid from day-to-day block
benefit, if not registered on the Maternity Programme • Includes 2 x 2D ultrasound scans per pregnancy. Should a 2D scan be substituted with a 3D or 4D scan, it will be funded up to the cost of a 2D scan 1 11
Medical and surgical appliances and prostheses – Includes mobility scooters, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment, foot orthotics and external prostheses • Applicable in and out of hospital • Subject to prescription by network GP
• Limited to R42 171 per family per year • Sub-limit of R16 454 for medical and surgical appliances per family per year • Shared sub-limit with in-hospital prosthetics and appliances of R4 631 for foot orthotics and prosthetics • Sub-limit of R1 323 for orthotic shoes, foot
inserts and levellers per beneficiary per year • Foot orthotics and prosthetics subject to formulary • R527 for crutches per beneficiary per year • R5 797 for wheelchairs per beneficiary per year • R8 432 per hearing aid per beneficiary per year • Bilateral hearing aids every
36 months • One CPAP device of up to R10 013 per beneficiary every 36 months • GP nomination and specialist referral rules apply • Subject to PMBs 111 1
Mental health (Consultations, assessments, treatment and/or counselling by GP, Psychiatrist, Psychologist) – Consultations, assessments, treatments and/or counselling by GPs, psychiatrists, psychologists • If out-of-hospital treatment offered as alternative to
hospitalisation, then hospital benefits will apply • Shared with in-hospital mental health limit of R18 592 per family per year • Sub-limit of R5 513 for out-of-hospital psychologist consultations • Limited to 1 individual psychologist consultation and 1 group psychologist
consultation per day • Educational and industrial psychologists excluded 1 11
Optical services (eye examinations, frames, lenses, permanent or disposable contact lenses and acute medicine) – All services included in benefit subject to optical managed care programme • Sub-limit of R2 329 per beneficiary every second benefit year and
annual limit of R4 656 per family • Frames limited to R1 359 • Limited to 1 eye examination per beneficiary per year • 1 frame and 1 pair of lenses per beneficiary every second year • No limit will be applied to the number of contact lenses that may be rendered to a
beneficiary, aside from the indicated financial benefit limits • Either spectacles or contact lenses will be funded in a benefit year, not both • Excludes variable tint and photochromic lenses • Benefit not pro-rated • Post-cataract surgery, optical PMB entitlement limited up to
the cost of bifocal lens and not more than R1 118 for both lens and frame, with a sub-limit of R221 for frame • Includes tinted lenses up to 35% tint for albinism and proven photophobia, subject to pre-authorisation • Excludes variable tint and photochromic lenses 1 1
Pathology – Subject to day-to-day block benefit • Limit of R2 263 per beneficiary per year and R4 534 per family per year shared with audiology, occupational therapy and speech therapy • Includes liquid-based cytology pap smear 1 1
Physiotherapy – Sub-limit of R2 263 per beneficiary and R4 518 per family per year shared with GP services – Post-hip, knee and shoulder replacement or revision surgery • 10 post-surgery physiotherapy visits (shared with in-hospital visits) up to a limit of R5 292
per beneficiary per event used within 60 days of surgery 11 11
Prescribed medicine and injection material – Subject to formulary • 30% co-payment on out-of-formulary medicine and voluntary use of non-DSP • Subject to MPL and MEL – Acute medical conditions • Limit of R3 719 per beneficiary and R11 154 per family per
year • Sub-limit of R555 for homeopathic medicine per family per year – Chronic medical conditions • CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of chronic medicine pharmacy DSP • Limit of R11 154 per beneficiary and
R22 461 per family per year • Unlimited for PMBs • Once limit is depleted, CDL benefit will be limited – Prescribed medicine from hospital stay (TTO) • TTO limited to 7 days • Payable from risk once acute benefit limit is exhausted – Self-medicine (OTC) • Schedule 0,
1 and 2 medicines covered • Event limit of R250 per beneficiary • Sub-limit of R937 per beneficiary per year • Annual family limit of R1 498 – Contraceptives • Sub-limit of R2 822 per beneficiary per year 111
Preventative care services – Payable from risk • Includes Influenza, HPV and Pneumococcal vaccination • HPV vaccination for female beneficiaries • Pneumococcal vaccination once every 5 years for beneficiaries at risk • Includes screening services provided by network
pharmacies 11
Primary care extender – Payable from risk • Shared limit between GP services, pathology and medical technology and prescribed medication • The additional benefit of R500 per beneficiary per year is available once the block benefit or specific sub-limits are exhausted
11 11
Screening services – Serum cholesterol, bone density scan, pap smear (including liquid-based cytology), prostate specific antigen, glaucoma screening, TB, syphilis, chlamydia, gonorrhoea, serum glucose, occult blood tests, Thyrotropin (TSH) for neonatal hypothyroidism,
mammogram and other screening according to evidence-based standard practice • Neonatal hypothyroidism screening test – TSH (Thyrotropin) tariff 4507 only • Once-off childhood hearing and optometry screening benefit • Includes screening services provided by network
pharmacies • Limited to 1 of each of the stated screening services per beneficiary per year 1
Radiology (advanced) – Shared limit with in-hospital advanced radiology of R22 309 per family per year • Specific authorisation required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies 1 11 1
Radiology (basic) – X-rays and soft tissue ultrasound scans • 2 x 2D ultrasound scans provided for by maternity benefit. Should a 2D scan be substituted with a 3D or 4D scan, it will be funded up to the cost of a 2D scan • Sub-limit of R3 703 per beneficiary and R6 787
per family per year 1
Renal dialysis – Subject to use of a Renal Dialysis Network DSP • If a non-network provider is voluntarily used, a co-payment of 30% will be applied per event 1 11