You should visit a GEMS network doctor who will confirm your HIV status in confidence, and provide you with counselling and support. To obtain benefits such as anti-retroviral medication, your doctor has to register you on the HIV Management Programme.

All information will be kept confidential. You will need to follow certain requirements, such as taking your medication strictly according to your doctor's instructions and undergoing regular check-ups and blood tests, to continue receiving benefits under the programme.

Anti-retroviral medicine is medicine used to treat HIV/AIDS. These medicines do not get rid of HIV/AIDS but they lower the amount of the HI virus in your blood. The HI virus is therefore not able to do as much damage to your immune system.

GEMS Network doctors receive special training in HIV/AIDS management. When you are registered on the HIV Disease Management Programme (DMP), your doctor will follow guidelines in monitoring and treating your condition. Monitoring includes regular medical check-ups; blood tests to check your response to treatment, and discussions with you to keep you informed and ensure you are comfortable with your treatment and management plan.

ART is a treatment using a combination of medicines to reduce the viral load (the amount of the HI virus in the blood). HIV-positive patients are required to first consult their GEMS Network doctor, who will confirm diagnosis and then register them on the HIV DMP. Once registered, and if needed, ART medicine is available from GEMS Network pharmacies.

To obtain further information on the HIV DMP call the confidential HIV line on 0860 436 736, or fax 0800 436 7329 or email [email protected]

Patients benefit from ART when the medicine is started at a specific stage of their illness when the CD4 blood count is less than 200 cells/mm3. If you are HIV-positive, you should register on the HIV DMP even if you are not at the stage where you require ART. You will still need regular clinical check-ups and blood tests to monitor your health.

Your state of health will worsen and you will become very ill. The doctor will educate and assist you on how to take your medication. If you are not following the doctor's instructions, despite assistance by the HIV DMP, you may lose this benefit.

These are the minimum benefits, in respect of relevant health services, that a scheme must provide to members and is prescribed by the regulations under the Medical Schemes Act. The scheme can, however, apply clinical criteria and managed healthcare protocols to the PMBs and stipulate that members make use of a designated service provider for the provision of PMB services.
Click here for more information about Prescribed Minimum Benefits (PMBs).

Click here for more information about the GEMS Network.

The Optometry Managed Care Programme manages the optometry benefits for GEMS members in accordance with the Scheme rules and ensures that patients are able to receive clinically essential services and materials.

The Optometry Managed Care Programme also has measures in place to prevent fraudulent claims and thus protecting the medical scheme, the service providers and most importantly, the members.

On the Beryl, Ruby, Emerald and Onyx options a member can claim for either spectacles or contact lenses, not both. The Sapphire option does not provide any contact lens benefit. It is therefore important to take your lifestyle and level of vision into consideration when making a choice between spectacles or contact lenses. Consult with your optometrist to determine the best option suitable for your needs.

Optical benefits are allocated to each beneficiary and cannot be transferred from one family member to another. Members have an allocated benefit for a two year period.
Click here for more information about the Optometry Managed Care Programme.

Limits are annually based (allocated per beneficiary per year) and new benefits are allocated each year. Any remaining benefits will not be carried over to the new year. This is in line with the Scheme Rules.

Limits apply to individual beneficiaries and cannot be shared amongst dependants. The funds are set per beneficiary, per year, as indicated in the Scheme Rules.

No, this cannot be done.

One dental consultation/examination per beneficiary is allowed every 6 months. This can include fillings, fluoride treatment, cleaning, scaling and polishing. All services are subject to an approved list of tariff codes, managed care protocols and processes.

The benefit is available for children under the age of 8 for severe dental treatment. In-hospital treatment is subject to pre-authorisation.

Authorisations do not guarantee payment of any claim. Payment of claims depends on your available benefits, Scheme Rules and procedures. If there is a difference in your treatment plan from the authorised treatment, your claims may be short paid. We suggest that any authorised treatment plan which has changed, be updated with the Scheme before treatment is received in order to avoid short payment or non-payment of claims. Benefits must also be available for planned procedures.