Word List

Acute medicine: Medicine prescribed to relieve symptoms of a temporary illness or condition, for example, an infection or a sprain.

Additional chronic disease list (ACDL): An additional list of chronic diseases that the Scheme provides chronic medicine benefits for. GEMS covers these diseases in addition to the 26 diseases that it must cover by law (the 26 diseases are given in the Chronic disease list).

Beneficiary: A person who can receive benefits from GEMS. A beneficiary is either the principal member on GEMS or one of their registered dependants.

Benefit: The amount of money that a member or dependant has allocated from the Scheme to spend on medical treatment and medicine, according to the relevant option (Sapphire, Beryl, Ruby, Emerald or Onyx) of the Scheme.

Chronic: A chronic condition is any condition which needs ongoing treatment, or a treatment for a period of at least three months. Examples of chronic conditions are asthma or diabetes.

Chronic disease list (CDL): A list of the 26 specific chronic diseases all medical schemes need to provide a minimum level of cover for, as stated by law.

Consultation: A visit to your doctor, surgeon or other healthcare provider to get a diagnosis or treatment. This also includes the times when your healthcare service provider visits you while you are in hospital.

CT and MRI scans: Special x-rays taken of the inside of your body to try to find the cause of a medical condition.

Designated service provider (DSP): A healthcare provider or group of providers chosen by the Scheme to provide diagnosis, treatment and care to members in respect of one or more PMB conditions. This includes doctors, pharmacies and hospitals. When you choose not to use a DSP, you may have to pay a portion of the cost of the consultation of treatment from your own pocket.

Formulary: The list of approved medicines, tests or services.

GEMS Tariff: The rate at which healthcare providers will be paid for services rendered to GEMS members.

General practitioners (GPs): Doctors who provide general healthcare services and do not only offer a specialised service.

Generic medicine: Medicine that has the same chemical ingredient, strength and form (such as a tablet or syrup) as the original brand name product. Generic medicine is as safe and effective as the original brand name product, but is usually cheaper.

Medicine list or formulary: A list of cost-effective medicines that guides the doctor in the treatment of specific medical conditions.

Medicine exclusion list (MEL): A list of medicines that GEMS does not cover for various reasons.

Medicine price list (MPL): A reference pricing system we use to work out the prices of groups of medicines. The medicines are grouped according to how similar they are in ingredients, strengths and form. If a member and service provider chooses to use medicine that is higher than the reference price, the member pays the difference.

Personal medical savings account (PMSA): The portion of your monthly contribution that is allocated to a savings account held in your name. The money in this account is used to pay for your out-of-hospital medical expenses.

Pre-authorisation (PAR): The process of informing GEMS of a planned procedure before the event, so that we can assess whether we will cover it.

Prescribed minimum benefit (PMB): A list of conditions that every medical scheme has to cover, according to the Medical Schemes Act. Each condition is linked with a specific treatment that is meant to be covered.

Preventative care: Treatment given to prevent or reduce the risk of getting a medical condition.

Principal member: The main member registered on the Scheme.

Professional dispensing fee (PDF): A maximum fee that a pharmacist or dispensing doctor may charge for their services. This
maximum is set out in South African law.

Registered dependant: A person who is dependent on the principal member and is registered by the Scheme to share in the benefits provided to the principal member.

Restricted medical scheme: A medical scheme that only employees from a particular organisation can belong to.

Scheme rate: The price agreed by the Scheme and its healthcare service providers for the payment of healthcare services provided by service providers to members of the Scheme.

Shared limit: A benefit that applies to two or more benefit categories. An example is the advanced radiology benefit with its out-of-hospital and in-hospital shared limit. If you use the full benefit for out-of-hospital benefits, the in-hospital benefits for this particular benefit category will also be finished.

Single exit price (SEP): The one price that a medicine manufacturer or importer charges for medicine to all its customers. This price is set out in South African law.

Specialists: Doctors who have specialised in a particular medical field, such as oncology, paediatrics or gynaecology.