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The GEMS DifferenceExperience

2018 Dental Provider Guide

01 Introduction 01

02 SapphireandBeryl:Generaladministration,benefitsandprocedurescovered 02

03 Ruby,EmeraldValue,EmeraldandOnyx:Generaladministration, benefitsandprocedurescovered 07

04 AllGEMSoptions:Generalexclusionsandrestrictions- excludesPMB(PrescribedMinimumBenefits) 12

05 Dentalmedicineformulary 15

06 Pre-authorisation 40

07 Claimprocedures 40

08 Memberverificationandvalidation 41

09 Exclusions 42

10 Exgratia 42

11 Forms 43

Table of Contents

Introduction

Dear Dental Provider

Welcometo2018.Thankyoufortakingcareoftheoralhealthneedsofourmembers.

ThisguidewillassistyouwiththedentistrybenefitsandSchememanagedcarerulesfor2018.Timeandagerules,generalprinciplesandexclusionsareallsetoutinthemanual.Howthisisappliedtothedifferentdentalproceduresandthespecificapplicationtothedifferentoptionsarealsostipulated.We recommend that you take time to familiarise yourselfwiththecontenttoensureoptimaldeliveryofdentalservicestoGEMSbeneficiariesaswellas topreventanyunnecessary frustrationwithinyourpractice.

One

NOTE: Shouldyouhaveanyqueriesregardingbenefits, rules, exclusions, pre-authorisationoranyquery regarding yourpatient’sSchemeoption,pleasecontactGEMSon0860 436 [email protected].

Exclusions Pre-authorisation

RulesBenefits

ItisourpriorityatGEMStoensureequitableaccesstoaffordableandcomprehensivehealthcarebenefitstoallourmembers.Werelyonyou,asavalueddentalprovider,toensureourmembers’expectationsarerealised.

IttakesateameffortbetweentheSchemeandhealthcareproviderstoensurehighqualityclinicalandadministrativeservicestoourmembers.Wethereforeextendaninvitationtoyoutobecomeanintegralpartofthis teambybecomingamemberof theGEMSDentalNetworkandFriendsofGEMS.FordetailsandimmediateassistanceonhowtojointhegrowingGEMSDentalNetwork,[email protected].

Pleasebeassuredthatwerecogniseandappreciateyourimportanceasa vital link in thedental service valuechain toensure thatGEMSbeneficiariesreceiveonlythehighestqualityofdentalcare.

We remain committed to ensuring that our beneficiaries receive theappropriatecare.

Dental Managed Care programmeTheDentalManagedCareprogrammeappliestoallGEMSoptionsnamelySapphire,Beryl,Ruby,EmeraldValue,EmeraldandOnyx.ThemotivationbehindDentalManagedCare is not to impingeon thepractitioner’s

diagnosisinanyway,buttoensurerational,appropriateandcosteffectivetreatmenttoallGEMSbeneficiarieswithinthedentalbenefitspectrumandbudgetaryparametersapplyingwithinsuchpatient’sschemeoption,inaccordancewithaccepteddentaltreatmentguidelinesandprotocols.

Pre-authorisation, pre-notification and patient registrationPatient registration: Duringthepatient’sfirstvisittoyourpracticeaonce-offdentalchartingandfulloralexaminationinassociationwithcode8101(aspernormalprescribedguidelinesassociatedwiththechargingofcode8101)needstobeperformedandthensubmittedtoGEMS.Pleaseensurethatyoudocomplywiththisrequirement.

The “DentalReport forPatientRegistration,Pre-notificationandPre-authorisation”(exampleincludedinthisguide)shouldbecompletedandforwardedtotheScheme.Thisallowsforthecentralisedcapturingofthepatient’sexistingoralhealthstatustoensureproperandappropriatedentalmanagedcareandriskmanagementinaccordancewithinternationallyrecognisedstandards.ItalsoallowsustocompileanactualanddynamicepidemiologicdatabaseoftheGEMSpatientpopulationforfuturebenefitandbudgetaryplanning.

Pre-authorisation and/or a treatment plan:Thisisrequiredforcertaindentalproceduresasindicatedintheprocedurescheduleswithin this guidepertaining to each specific option. Theyinclude,butarenotlimitedto,certainspecialisedandsurgicalprocedures,orthodontics,periodontaltreatmentandanyproceduresplannedtobeperformedinanoperatingtheatreorunderconscioussedation.

Where pre-authorisation is required for periodontal treatment the“PeriodontalPre-authorisationForm” (example included in thisguide)shouldbecompletedandforwardedtotheScheme.

Wherepre-authorisationand/ortreatmentplansarerequired,thestandard“PatientRegistration,Pre-notificationandPre-authorisation”formshouldbecompleted.Itisonlynecessarytocompletetheapplicablesections,forinstance,it isnotnecessarytocompletethechartingsectionwitheachrequest.

Note: The “Dental Report for Patient Registration” and “DentalReportforPeriodontalPre-authorisation”formsareavailableontheGEMSwebsiteatwww.gems.gov.za.Emailthecompletedformtoenquiries@gems.gov.zaorfaxto0861004367.

Welookforwardtobeingofservicetoyouandyourpatients.

2018 Dental Provider Guide 1

Sapphire and Beryl: General administration, benefits and procedures covered

Summarised benefits offered by Sapphire and Beryl:

Summarised benefits offered by Sapphire: (For a detailed benefit matrix refer to page 4)

• ServicesmustbeprovidedbyaGEMSDentalNetworkprovider

only.

• Examinationsandpreventativetreatment:Twoconsultation/examination

andpreventativetreatmentepisodesperbeneficiaryperbenefityear.

• Restorativetreatment–- limitedtoatotaloffourrestorationsper

beneficiaryperyear.

• Posteriorresinspaidatthesamerandvalueasamalgamfillings.

• Painandsepsis–refertable(page4)forprocedurescovered.

• Oneemergencyvisitperbeneficiaryperyear.

• Dentureslimitedtotheapproved2018Schemetariff.

• Alldenturessubjecttopre-authorisation.

• Nospecialiseddentistrybenefit-limitedtoPMB’s.

• Radiology:Allservicesaresubjecttoanapprovedlistoftariffcodes,

managedcareprotocolsandprocesses.

Summarised benefits offered by Beryl: (For a detailed benefit matrix refer to page 4)

• ServicesmustbeprovidedbyaGEMSDentalNetworkprovider

only.

• Examinationsandpreventativetreatment:Twoconsultation/examination

andpreventativetreatmentepisodesperbeneficiaryperbenefityear.

• Restorative treatment– limited toa totalof four restorationsper

beneficiaryperyear(pre-authorisationneededformorethanfour

fillings).

• Painandsepsis–refertable(page4)forprocedurescovered.

• Oneemergencyvisitperbeneficiaryperyear.

• Denturesandspecialiseddentistryservices(periodontaltreatment,

partialmetalframedenturesandmaxillo-facialtreatment)limitedto

R3434perbeneficiaryperyear.

• Alldenturesandspecialiseddentistrysubjecttopre-authorisation.

• Allservicesaresubjecttoanapprovedlistoftariffcodes,managed

careprotocolsandprocesses.

Charting:Pleasenotethataspartofcode8101aonce-offpatient

chartingandoral-examinationwillberequiredforeachbeneficiary

visitingyourpracticeforthefirsttime.

ThechartingistobesubmittedtotheSchemeonthe“DentalReport

forRegistration,Pre-notificationandPre-authorisation”form.

Sapphire and Beryl Options – Specific rules that apply

Essential dentistry

• Approvedlistofservices/codesarecoveredat100%oftheagreed

tariffsubjecttotheavailabilityoffunds.

• Painandsepsistreatment:

>Codescovered–8132,8201andcode8307(code8307only

appliesonprimaryteeth).

• Extractions:

>Onlycoveredifclinicallyindicated.

• Generalanaestheticsandconscioussedation:

>SubjecttotherulesoftheScheme,relevantmanagedcareprotocols

andpre-authorisation.

Emergency dentistry

• Approveddentalcodesare8132;8201and8307(asperpainand

sepsistreatment).

• Emergencypainandsepsistreatmentonly.

• Pulpotomy(8307)onprimaryteethonly.

• Anyadditionaltreatmentrequiresfundingbypatient.

• Oneeventperbeneficiaryperbenefityearallowedforemergency

dentistry.

Dentures

FortheSapphireandBeryloption:

• Onesetofplasticdenturesallowedperbeneficiaryper48month

benefitcycle.

• Asetofdenturesisdefinedasfollows:

>Completeupperandlowerdentures

oCompleteupperorlowerdentures(nottwoupperortwo

lower)

>Partialupperandlowerdentures

oPartialupperorlowerdenture(nottwopartialupperortwo

partiallower)

Two

2018 Dental Provider Guide2

• Onlymembersandbeneficiariesovertheageof21qualifyforthis

benefit.

• Subjecttopre-authorisation.

• Beryl:Partialmetalframedentureavailableonceperbeneficiaryin

a5-yearperiod.Subjecttopre-authorisationandonlyavailableto

membersolderthan21.CoveredundertheSpecialisedDentistry

limitofR3434perbeneficiaryperyear.

The following table summarises the reimbursement codes relating to dentures:

• WhenclaimingviaElectronicDataInterchange(EDI),useindividualninecodesfordentallaboratories.Laboratoryinvoicestoberetainedby

thepracticeforpossibleauditingpurposes.

• Whensubmittingpaperclaimsuseindividualninecodesfordentallaboratoriesandsubmitthedentallaboratoryinvoicetogetherwiththepaper

invoice.

• Noclaimwillbeacceptedwithouttheprofessionalfeeandlaboratorycodessubmittedtogetherorbeingmatchedintheeventofalaboratory

performingself-billing.

CODES NOT FUNDED CODES FUNDED

8658(interimcompletedenture) 8231(completedentures–maxillaryandmandibular)

8659(interimpartialdenture) 8232(completedentures–maxillaryormandibular)

8661(diagnosticdentures) 8233(partial–onetooth)to8241(partialdenture–nineormoreteeth)

8244(immediateupperdenture) 8269(repairofadentureorotherintraoralappliance)

8245(immediatelowerdenture) 8271(addtoothtoexistingpartialdenture)

8281,8663,8279(metalbasecodes)ontheSapphireoption8273 (impression to repair ormodify a denture, or other removable

intraoralappliances

8099 8259(rebasecompleteorpartialdenture(laboratory)

8263(relinecompleteorpartialdenture(intraoral)

Individualninelaboratorycodes

Please note:

• NobenefitformetalbasetopartialorcompletedenturesfortheSapphireoption

• Noadditionalcoverifdenturesarelostduetonegligence

• Amotivationisrequiredforthereplacementofdentures.PleasedirectallmotivationstotheGEMScallcentreon0860436777oremailGEMS

[email protected]


CODE CODE DESCRIPTION LIMITATIONSCOVERED:

SAPPHIRE

COVERED:

BERYL

8101 Consultation Twoperbeneficiaryperyear Yes Yes

8104Examinationforaspecificproblemnot

requiringfullmouthexaminationTwoperbeneficiaryperyear Yes Yes

8107 Intraoralradiographs,perfilm Maximumoftwoperbeneficiaryperyear Yes Yes

8112 Bitewings Maximumoffourperbeneficiaryperyear Yes Yes

8115 PanoramicX-rayBenefitfromtheageof6–maximum

oneevery3yearsYes Yes

8155 Polishing–completedentition

Twoperbeneficiaryper12months.

Cannotbechargedwith8159insame

year

Yes Yes

8159 ScalingandpolishingTwoperbeneficiaryper12months;only

overtheageof12Yes Yes

8161 Topicalapplicationoffluoride(children)Fromtheageof3totheageof11.Once

perbeneficiaryper12monthsYes Yes

8162 Topicalapplicationoffluoride(adults)Fromtheageof12totheageof16.

Onceperbeneficiaryper12monthsYes Yes

8163 Fissuresealant,pertooth

Patientyoungerthan14;maximumof

twoperquadrantonposteriorpermanent

teethonly

Yes Yes

8341 Amalgamonesurface

Anyfouramalgamfillingsperbeneficiary

peryear.Subjecttoanoveralllimitoffour

restorationsperbeneficiaryperyear

Yes Yes

8342 Amalgamtwosurfaces

8343 Amalgamthreesurfaces

8344 Amalgamfourandmoresurfaces

Table of benefits: Sapphire and Beryl:



SAPPHIRE

COVERED:

BERYL

8351 Resinrestoration,onesurfaceanterior

Anyfourresinfillingsperbeneficiaryper

year(anterior).Subjecttoanoveralllimit

offourrestorationsperbeneficiaryper

year.

Yes Yes

8354 Resinrestoration,fourandmoresurfaces

8367 Resinrestoration,onesurfaceposterior

Anyfourresinfillingsperbeneficiaryper

year(posterior).Subjecttoanoveralllimit

offourrestorationsperbeneficiaryper

year.

Yes,buttothe

sameRandvalue

assamesurfaces

amalgamfilling.

Yes

8368 Resinrestoration,twosurfacesposterior

8369Resinrestoration,threesurfaces

posterior

8370 Resinrestoration,fourandmoresurfaces

8307 Amputationofpulp(pulpotomy) Onlyonprimaryteeth Yes Yes

8132Rootcanaltherapy–grosspulpal

debridement Yes Yes

8201

Extraction,singletooth.Code8201

ischargedforthefirstextractionina

quadrant.

Anyfournon-surgicalextractionsper

beneficiaryperyear–ONLYifclinically

indicated.

Yes Yes

8202

Extraction,eachadditionaltooth.

Code8202ischargedforeachadditional

extractioninthesamequadrant.

Anyfournon-surgicalextractionsper

beneficiaryperyearapply(inassociation

withcode8201)

Yes Yes

8937 Surgicalremovaloftooth*Quantitylimitoftwo.Pre-authorisation

necessaryformorethantwo

Yes.Benefitfrom

theageof12

Yes.Benefitfrom

theageof12

8213Surgicalremovalofresidualroots,first

tooth-pertooth*

Maximumofoneprocedureapplies.

Morethanonerequiresclinical

motivation.

Yes.Benefitfrom

theageof12

Yes.Benefitfrom

theageof12

8214Surgicalremovalofresidualroots,

secondandsubsequentteeth’sroots*

Maximumofoneprocedureapplies.

Morethanonerequiresclinical

motivation.

Yes.Benefitfrom

theageof12

Yes.Benefitfrom

theageof12

8941Surgicalremovalofimpactedtooth–first

tooth*Pre-authorisationrequiredforin-hospital Yes Yes

8943Surgicalremovalofimpactedtooth–

secondtooth*Pre-authorisationrequiredforin-hospital Yes Yes

8945Surgicalremovalofimpactedtooth–

thirdandsubsequentteeth*Pre-authorisationrequiredforin-hospital Yes Yes

8220 Sutures

Inassociationwithsurgicalextractions

and/orimpactions.Quantitylimitedto

onceperyear

Yes Yes

8935 Treatmentofsepticsocket Yes Yes

Table of benefits: Sapphire and Beryl (continued):



SAPPHIRE

COVERED:

BERYL

8109

Infectioncontrol/barriertechniques.

Code8109includestheprovisionbythe

dentistofnewrubbergloves,masksetc.

foreachpatient

Twopervisit Yes Yes

8110 Sterilisedinstrumentation Onepervisit Yes Yes

8145 Localanaesthetic Onepervisit Yes Yes

8231Completedentures

- maxillaryandmandibular

Onesetofplasticdenturesallowedper

beneficiaryper48months.

Pre-authorisationnecessary.

ONLYmembersandbeneficiariesover

theageof21.

ONLYplasticdenturesfortheSapphire

option.

*Beryl:Metalframeworkevery5years.

Yes Yes

8232Completedentures–maxillaryor

mandibularYes Yes

8233 Partialdenture(resinbase)–Onetooth Yes Yes

8234 Partialdenture(resinbase)–Twoteeth Yes Yes

8235 Partialdenture(resinbase)-Threeteeth Yes Yes

8236 Partialdenture(resinbase)–Fourteeth Yes Yes

8237 Partialdenture(resinbase)–Fiveteeth Yes Yes

8238 Partialdenture(resinbase)–Sixteeth Yes Yes

8239 Partialdenture(resinbase)Seventeeth Yes Yes

8240 Partialdenture(resinbase)-Eightteeth Yes Yes

8241Partialdenture(resinbase)–Nineteeth

andmoreYes Yes

8259 Rebasecompleteorpartialdentures(lab)Rebaseonlyallowedonceeverytwo

yearsYes Yes

8269 RepairdentureCannotbecompletedwith6monthsof

fittinganewdentureYes Yes

8263Relinecompleteorpartialdentures(chair

side)Relineonlyallowedonceeverytwoyears Yes Yes

8271 AddtoothtoexistingpartialdenturesCannotbecompletedwithin6monthsof


8273 Impressiontorepair/additionCannotbecompletedwithin6monthsof


*Please notethatMaxillo-facialsurgeryissubjecttoanannualsub-limitofR20823perfamilyontheSapphireandBeryloptions

Table of benefits: Sapphire and Beryl (continued):


Ruby, Emerald Value, Emerald and Onyx: General administration, benefits and procedures covered

Summarised benefits covered on Ruby, Emerald Value, Emerald and OnyxSummarised benefits covered on Ruby:

• ServicesnotlimitedtoGEMSDentalNetworkProviders• Shareddentalsub-limitofR3200perbeneficiaryperyearforin-

hospitaldentistryprofessionalfeesandallout-of-hospitaldentistry• Conservativeandrestorativedentistry(includingplasticdentures): >100%ofSchemeratesubjecttoavailablefunds• Specialiseddentistry(includingmetalbasepartialdentures): >Nopre-authorisationrequiredforpartialmetalbasedentures >Pre-authorisation required for all other specialiseddentistry

procedures >Excludesosseo-integratedimplants,allimplantrelatedprocedures

andorthognathicsurgery >Excludesorthodontictreatmentonpatientsolderthantheageof

21• Generalanaesthesiaandconscioussedation: >Subject topre-authorisationandmanagedcareprotocolsand

processes >Onlyapplicabletobeneficiariesundertheageof6,severetrauma

andimpactedthirdmolars >Impactedthirdmolars:200%ofSchemeratepayableforremoval

underconscioussedationindoctor’srooms >Anaesthetistsarerequiredtoobtainaseparateauthorisationfor

dentalrelatedconscioussedationprocedures

Summarised benefits covered on Emerald Value and Emerald:

• ServicesnotlimitedtoGEMSDentalNetworkProviders• Shareddentalsub-limitofR4918perbeneficiaryperyearforin-

hospitaldentistryprofessionalfeesandallout-of-hospitaldentistry• Conservativeandrestorativedentistry(includingplasticdentures): >100%ofSchemeratesubjecttoavailablefunds• Specialiseddentistry(includingmetalbasedentures): Nopre-authorisationrequiredforpartialmetalbasedentures >Pre-authorisation required for all other specialiseddentistry

procedures >Excludesosseo-integratedimplants,allimplantrelatedprocedures


21• Generalanaesthesiaandconscioussedation: >Subject topre-authorisationandmanagedcareprotocolsand




dentalrelatedconscioussedationprocedures

Charting: Please note that as part of code 8101 a once-off

patientchartingandoral-examinationwillberequiredforeach

beneficiaryvisitingyourpracticeforthefirsttime.Thecharting

is to be submitted to the Scheme on the “Dental Report for

Registration,Pre-notificationandPre-authorisation”form.

Three


Please ensure that pre-authorisations are performed prior to commencing treatment where indicated e.g. specialised dentistry, orthodontic treatment,

in-hospital (theatre) and conscious sedation associated treatment.

Summarised benefits covered on Onyx:

• ServicesnotlimitedtoGEMSDentalNetworkProviders• Shareddentalsub-limitofR8775perbeneficiaryperannumforin-

hospitaldentistryprofessionalfeesandallout-of-hospitaldentistry• Conservativeandrestorativedentistry(includingplasticdentures): >100%ofSchemeratesubjecttoavailablefunds.• Specialiseddentistry(includingmetalbasedentures): >Pre-authorisationneeded(exceptformetalbaseddentures) >Excludesosseo-integratedimplants,allimplantrelatedprocedures


21

• Generalanaesthesiaandconscioussedation: >Subject topre-authorisationandmanagedcareprotocolsand




dentalrelatedconscioussedationprocedures.

Charting: Please note that as part of code 8101 a once-off

patientchartingandoral-examinationwillberequiredforeach

beneficiaryvisitingyourpracticeforthefirsttime.Thecharting

is to be submitted to the Scheme on the “Dental Report for

Registration,Pre-notificationandPre-authorisation”form.


RUBY EMERALD VALUE* & EMERALD ONYX

Dental consultation

yearly check-up

Twoannualconsultationsperbeneficiary,

oneevery6months

Twoannualconsultationsperbeneficiary,

oneevery6months

Two annual consultations per

beneficiary,oneevery6months

Diagnostics8107: diagnosis and treatment

procedureswherenecessary

8107:diagnosisandtreatmentprocedures

wherenecessary

8107: diagnosis and treatment

procedureswherenecessary

8108:benefitfromtheageof6-one

every24months

8108:benefitfromtheageof6-oneevery

24months

8108:benefitfromtheageof6-one

every24months

8112:maximumoffourper12months 8112:maximumoffourper12months8112:maximumof four per 12

months

8115: benefit from the age of 6 –

maximumoneevery36months

8115:benefitfromtheageof6–maximum

oneevery36months

8115:benefitfromtheageof6–

maximumoneevery36months

8116,8114:fororthodontictreatment

only; benefit is subject to obtaining

pre-authorisation

8116, 8114: for orthodontic treatment

only; benefit is subject to obtainingpre-

authorisation

8116, 8114: for orthodontic

treatment only; benefit is subject

toobtainingpre-authorisation

Infection control8109: infection control / barrier

techniques-twicepervisit

8109:infectioncontrol/barriertechniques

-twicepervisit

8109: infection control / barrier

techniques-twicepervisit

8110:sterilisedinstrumentation-once

pervisit

8110: sterilised instrumentation - once

pervisit

8110: sterilised instrumentation -

oncepervisit

Preventative dentistryScaleandpolish8159:onceevery6

months–fromtheageof12only

Scaleandpolish8159:onceevery6months

–fromtheageof12only

Scaleandpolish8159:onceevery

6months–fromtheageof12only

Polish8155:onceevery6months Polish8155:onceevery6months Polish8155:onceevery6months

Fluoride treatment: 8161paid once

every6monthsundertheageof12

Fluoridetreatment:8161paidonceevery

6monthsundertheageof12

Fluoridetreatment:8161paidonce

every6monthsundertheageof12

Fluoride treatment: 8162paid once

every6monthsfromtheageof12to

themaximumageof16

Fluoridetreatment:8162paidonceevery6

monthsfromtheageof12tothemaximum

ageof16

Fluoridetreatment:8162paidonce

every6monthsfromtheageof12

tothemaximumageof16

Dentalsealant:maxtwoperquadrant

andonceeverytwoyearspertooth–

nobenefitiftoothalreadyinmouthfor

morethan4yearsandforolderthan

theageof18

Dentalsealant:maxtwoperquadrantand

onceeverytwoyearspertooth–nobenefit

iftoothalreadyinmouthformorethan4

yearsandforolderthantheageof18

Dental sealant – max two per

quadrantandonceeverytwoyears

pertooth–nobenefitiftoothalready

inmouthformorethan4yearsand

forolderthantheageof18

Restorations/ fillings

Benefits available where clinically

indicated–allowedoncepertoothin

aoneyearperiod

Benefitsavailablewhereclinicallyindicated–

allowedoncepertoothinaoneyearperiod

Benefits availablewhere clinically

indicated–allowedoncepertooth

inaoneyearperiod

Dentures

One set of full, or full upper or full

lower,orpartialupperand/orpartial

lowerplasticdenturesevery4years.

Relines,rebase,softbaseeverytwo

years.Metalframeworkevery5years.

Onesetoffull,orfullupperorfulllower,or

partial upper and/or partial lowerplastic

denturesevery4 years.Relines, rebase,

softbaseeverytwoyears.Metalframework

every5years.

One set of full, or full upper or

full lower, or partial upper and/or

partiallowerplasticdenturesevery

4years.Relines,rebase,softbase

everytwoyears.Metalframework

every5years.

Endodontic (Root

canal) treatment

Pre-authorisationnecessaryforpatients

undertheageof14.

Pre-authorisation necessary for patients

undertheageof14.

Pre-authorisation necessary for

patientsundertheageof14.

Table of benefits: Ruby, Emerald Value, Emerald and Onyx:


RUBY EMERALD VALUE* & EMERALD ONYX

Note:8132notallowedonsameday

asroottreatment.Amaximumofthree

treatmentassociatedperiapicalX-rays

allowed(thereafter,pre-authorisation

necessary)

Note:8132notallowedonsamedayasroot

treatment.Amaximumofthreetreatment

associated periapical X-rays allowed

(thereafter,pre-authorisationnecessary)

Note:8132notallowedonsame

dayasroottreatment.Amaximumof

threetreatmentassociatedperiapical

X-rays allowed (thereafter, pre-

authorisationnecessary)

SPECIALISED DENTISTRY

Crowns and bridgesPre-authorisation necessary.Benefit

oncepertoothper4years

Pre-authorisationnecessary.Benefitonce

pertoothper4years

Pre-authorisationnecessary.Benefit

oncepertoothper4years

OrthodonticsTreatmentplannecessary–limitedto

patientsunder21

Treatment plan necessary – limited to

patientsunder21years

Treatmentplannecessary–limited

topatientsunder21

Periodontics Treatmentplannecessary Treatmentplannecessary Treatmentplannecessary

Maxillo-facial & oral/

dental surgery

Pre-authorisation necessarywhen

done in-theatre or under conscious

sedation.Impactedwisdomteethpaid

at200%ofratewhenperformedunder

conscioussedationindentist’srooms

Pre-authorisation necessarywhendone

in-theatre or under conscious sedation.

Impactedwisdomteethpaidat200%of

ratewhenperformedunder conscious

sedationindentist’srooms

Pre-authorisationnecessarywhen

donein-theatreorunderconscious

sedation.Impactedwisdomteeth

paidat200%ofratewhenperformed

underconscioussedationindentist’s

rooms

DENTAL HOSPITALISATION

Dental hospitalisation*

Onlyallowedundertheageof6,bony

impactionsandseveretrauma(PMB).

Subjecttopre-authorisation,treatment

protocolsandPMBconditionsapplying

Only allowedunder the ageof 6, bony

impactions and severe trauma (PMB).

Subject to pre-authorisation, treatment

protocolsandPMBconditionsapplying

Onlyallowedunder theageof6,

bonyimpactionsandseveretrauma

(PMB).Subjecttopre-authorisation,

treatment protocols and PMB

conditionsapplying

*EmeraldValue:Non-networkhospitalusewillattractaR10000co-payment.

General principles applying:

• AlldentalproceduresarecoveredaspertherulesapplyingperspecificSchemeoption

Table of benefits: Ruby, Emerald Value, Emerald and Onyx (continued):


• Allspecialiseddentistryandin-hospital

dentistryaresubjecttopre-authorisation

beforecommencementoftreatment

exceptintheeventofanemergency

where retrospective authorisation

shouldbeobtainedwithin72working

hoursaftertheevent

• An authorisation granted is not a

guaranteeofpayment.Paymentstrictly

remainssubjecttotheavailabilityof

funds

• Confirmation of benefits is not a

guarantee of payment – payment

strictlyremainssubjecttotheavailability

offunds

• Hospital authorisations are valid for

aperiodofonemonthandallother

authorisationsarevalidforaperiod

of3months.

• Where the dental treatment plan

changes,theauthorisationsmustbe

updatedpriortosubmittingtheclaim.

Orthodontic treatment:

• Benefitsonlyapplicableonbeneficiaries

undertheageof21

• Authorisation and a treatment plan

apply andbenefits subject to prior

evaluation according to the ICON

criteria–IndexofComplexity,Outcome

andTreatmentNeed.

• Onceapprovedaninitialamountwillbe

payableandthebalanceinincrements

subjecttotheavailabilityoffunds

• Approved treatmentplans are valid

foroneyear

• Intheeventthatacasegetstransferred

toanotherprovideronlythebalance

due asper original treatment plan

wouldbecovered

• Orthodontic Exclusions: Refer to

“GeneralExclusionsandRestrictions”.

• When relocatingorseekingsecond

opinions,kindlyrequestrecordsfrom

the first ServiceProvider to avoid

incurringoverexposuretoradiation.

Hospitalisation

• Onlycoveredforpatientsunderthe

ageof6,bonythirdimpactionsand

severetraumaasperSchemerules.

• Nootherproceduresapply

• Subjecttopre-authorisation

• Childrenundertheageof6:

> Only considered where no

otheroptionsareavailable.

> All procedures necessary to

be completed in one theatre-

associatedevent.

>Only necessary restorative and

surgical (e.g. extractions)

proceduresmaybe performed.

No preventative treatment

(polish, fluoride treatment,

f issure sealants) wil l be

coveredintheatre.

• Emerald Value option: A co-payment

of R10 000 will be levied should you

not utilise a DSP hospital. Kindly

ensure this is checked when pre

authorisation is done.

1 2 3


Four

All GEMS options: General exclusions and restrictions - excludes PMB (Prescribed Minimum Benefits)

Diagnostic/preventative treatment• Specialreport

• Dentaltestimony

• Microbiologicalstudies

• Cariessusceptibilitytests

• Diagnosticmodelsonlycoveredinassociationwithorthodontictreatment

• Appointmentnotkept

• Nutritionalcounselling

• Tobaccocounselling

• Oralhygieneinstructionand/orassociatedvisits

• Removalofgrosscalculus

• Behaviourmanagement

• Costoftoothbrushes,toothpastesandmouthwashes

• Fissuresealantsinpatientsolderthantheageof18orwhereteethhavebeeninthemouthformorethan4years

• Oraland/orfacialimage(digitalandconventional)

-onlycoveredwhereorthodontictreatmentapplies

• Fluoridetreatmentforpatientsolderthan16yearsofage

Fillings, restorations• Resinbondingforrestorationschargedseparatelyfromtherestoration

• Enamelmicroabrasion

• Electivereplacementoffillings

• Goldorgoldfoilrestorations

Dentures• Diagnosticdentures

• Snoringapparatus

• Clasporrest–castgold

• Clasporrest–wroughtgold

• Inlayindenture

• Metalbasetofulldentures

• Metalframesforpartialdentureslimitedtooneperjawandonceevery5years


Crown and bridge• Whereanunderlyingperiodontalcondition(e.g.extensivelossofalveolarbone)compromisesanacceptabletermprognosis

• Wherealackofremainingtoothstructurecompromisesanacceptableprognosis

• Whereenoughremainingtoothstructuredoesnotjustifyacrownastherestorationofchoice

• Onafailedrootcanaltreatedtooth

• Forcosmeticreasons

• Allowedoncepertootheveryfouryears

• Emergencycrownsnotplacedforimmediateprotectionofinjuredteeth

• Temporaryandprovisionalcrownsincludinglabcosts

• Ponticsonsecondmolars

• Onprimaryteethorthirdmolars

• Costofgold,semi-preciousmetalandplatinumfoil

• 8570–computergeneratedrestoration:Labnotallowedwiththiscode(only8560)

ImplantsAllimplantrelatedclinicalandlaboratoryassociatedprocedures(includesimplantplacement,costofcomponents,restorations/crowns/

bridges/dentures/repairsassociatedwithimplants)

Endodontic treatment• Onthirdmolars

• Onprimaryteeth

• Emergencyrootcanaltreatmentchargedonthesamedayasthecompletedrootcanaltreatment

• Re-treatmentnotcoveredwithintwoyearsofinitialtreatment

• Motivationrequiredfortreatmentundertheageoffourteen(14)

Orthodontic treatment exclusions• Re-treatmentoforthodontictreatment

• Lostappliancesnotcovered

• Lingualorthodonticsnotcovered

• Ceramicbracketsnotcovered

• Re-fixingoforthodonticbracketsnotcovered

• Retainerslimitedtooneperjaw

• Treatmentplanningfororthognathicsurgery


In-hospital (theatre)• Onlycoveredforpatientsundertheageofsix,bonythirdimpactionsandseveretraumaasperSchemerules-nootherprocedures

apply

• Preventativedentalproceduresaspartofthedentaltreatmentperformedonchildrenundertheageofsixnotcovered

Other• Cosmeticdentistry

• ThetreatmentofanycomplicationrelatedtotreatmentnotfundedbytheScheme.

• Intramuscularandsubcutaneousinjections

• Allproceduresrelatedtobleaching(exceptinternalbleachingonpreviouslyendodonticallytreatedteeth)

• Periochipreplacement

• Treatmentplancompleted(code8120)

• Costofmineraltrioxide

• Ozonetherapy

• Costofgold,semi-preciousmetalandplatinumfoil

• Orthognathicsurgeryandrelatedhospitalcosts

• Occlusaladjustmentminor(formajorocclusaladjustmentpre-authorisationnecessary)

• Boneregenerationprocedures

• Costofboneregenerative/repairmaterial

• Anylabcostswheretheassociatedprocedureisnotcovered

• Inlaysandonlays:

>Excludetoothnumbersonetothreeinallquadrants

>Nobenefitforgoldorpreciousmetal

>Allowedonceeveryfouryears

• MRIorCATscansfordentalpurposesnotcovered


Medicine may be prescribed:

FiveDental medicine formulary

Please note:Providertradenamesarenotlistedonformulary,allowingforgenericsubstitution,butapplyingReferencePricingandExclusionslists.

• AccordingtotheGEMSdentalmedicineformulary >ByanapprovedGEMSnetworkdentistordentaltherapist

(withintheirscope)

• IntheeventoftheSapphireorBeryloptions: >MedicinemustbedispensedbyapprovedGEMSnetworkor

courierpharmaciesordispensingdentists.

PleaserefertotherespectiveformulariesthatapplytotheSapphire/BerylandRuby/EmeraldValue/Emerald/Onyxoptionsbelowfordetailed

guidance.

A. GEMS Sapphire and Beryl dental medicine formulary 2018Key to quantities and limitations1. “Consumables”meansthemedicationmayonlybeadministrated

byaDSPattherooms.Allinjectablesareconsumablesand

claimsforscriptsgiventopatientstocollectfromDSPpharmacies

willberejected.

2. “MaxRx/7days&3Rx/annum”meansascriptfilleduptoa

maximumofsevendays’medicinesupplyandthreeprescriptions

peryearcanbeclaimed.

3. BenefitsformedicinearesubjecttoReferencePricing(MPL)and

exclusionlists(MEL).ShouldthecostoftheitemexceedMPL,the

patientwillbeliableforpaymentofthedifferenceincost.Ifthisis

thecasepleaseinformthepatientthatitwillbeforhis/herown

personalaccount.

4. Dentaltherapistsmayprescribeasperthelatestgovernment

gazettepublishedbytheDepartmentofHealth.


MIMSMIMS

DESCRIPTIONACTIVE INGREDIENT SCHEDULE

ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

2. ANAESTHETICS

2.2Local

anaesthetics

LidocaineHClLocalInj

1%4 IJ SOLN A Consumables



LidocaineInj2%w/

Epinephrine-1:800004 IJ SOLN A Consumables

3. ANALGESICS

3.2. Analgesics and antipyretics

3.2.

Analgesics

and

antipyretics

IbuprofenSusp100

MG/5ML2 OR SUSP A

Max200ml/Rx

&3Rx/annum

ParacetamolElixir120

MG/5ML0 OR ELIX A

Max200ml/Rx

&3Rx/annum

ParacetamolSuppos

125MG2 RE SUPP A

Max1op/Rx&

1Rx/annum

ParacetamolSuppos

250MG2 RE SUPP A

Max1op/Rx&

1Rx/annum

ParacetamolTab500MG 0 OR TABS AMaxRx/7days

&3Rx/annum

3.3

Combination

analgesics

Paracetamolw/Codeine

Tab500-10MG1 OR TABS A

MaxRx/7days

&3Rx/annum

Paracetamolw/Codeine

Syrup150-4MG/5ML1 OR SYRP A

Max100ml/Rx

&3Rx/annum

Acetaminophen-

Meprobamate-Caff-Cod

320-150-32-8MG

5 OR TABS AMaxRx/7days

&3Rx/annum

Acetaminophen-


320-150-48-8MG

5 OR CAPS AMaxRx/7days

&3Rx/annum

Paracetamol-

Promethazinew/

CodeineSyrup120-6.5-5

MG/5ML

2 OR SYRP AMax100ml/Rx

&3Rx/annum

4. MUSCULO-SKELETAL AGENTS

4.1 Non-steroidal anti-inflammatory agents

4.1.1COX

inhibitorsIbuprofenTab200mg 3 OR TABS A

MaxRx/7days

&3Rx/annum

IbuprofenTab400mg 3 OR TABS AMaxRx/7days

&3Rx/annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

11. EAR, NOSE AND THROAT

11.3 Mouth and throat preparations

11.3

Mouth

and throat

preparations

BenzocaineLozenge

10MG1 MT LOZG A

Max20l/Rx&4

Rx/annum

ChlorhexidineGluconate

Soln0.2%0 MT SOLN A

Max200ml/

annum

Povidone-Iodine

Mouthwash1%0 MT SOLN A

Max200ml/

annum

TetracaineHClOintment

0.5%1 MT OINT A

Max1op/

annum

18. ANTI-MICROBIALS

18.1. Beta-lactams

18.1.1 Penicillins

Amoxicillin&K

ClavulanateForSusp

125-31.25MG/5ML

4 OR SUSR AMax4fills/

annum

Amoxicillin&K

ClavulanateForSusp

250-62.5MG/5ML


annum

Amoxicillin&K

ClavulanateForSusp

400-57MG/5ML


annum

Amoxicillin&K

ClavulanateTab250-125

MG

4 OR TABS AMax4fills/

annum

Amoxicillin&K


MG


annum

Amoxicillin&K


MG


annum

Amoxicillin(Trihydrate)

ForSusp125MG/5ML4 OR SUSR A

Max4fills/

annum



Max4fills/

annum


Cap250MG4 OR CAPS A

Max4fills/

annum


Cap500MG4 OR CAPS A

Max4fills/

annum

Ampicillin-CloxacillinCap

250-250MG4 OR CAPS A

Max4fills/

annum

Ampicillin-CloxacillinFor

Susp125-125MG/5ML4 OR SUSR A

Max4fills/

annum

CloxacillinSodiumCap

250MG4 OR CAPS A

Max4fills/

annum


500MG4 OR CAPS A

Max4fills/

annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

PenicillinGProcaine

IntramuscularSusp

300000Unit/ML

4 IM SUSP A Consumables

PenicillinGBenzathine

ForIntramuscularSusp

2400000Unit

4 IM SUSR A Consumables

PenicillinVPotassiumFor

Soln125MG/5ML4 OR SOLR A

Max4fills/

annum

PenicillinVPotassium

Tab250MG4 OR TABS A

Max4fills/

annum

18.1.2Cephalospor-

ins

CefaclorForSusp187

MG/5ML4 OR SUSR A

Max2fills/

annum

CefaclorForSusp375

MG/5ML4 OR SUSR A

Max2fills/

annum

CefaclorMonohydrate

TabSR12HR375MG4 OR TB12 A

Max2fills/

annum

CefadroxilCap500MG 4 OR CAPS AMax2fills/

annum

CefadroxilForSusp250

MG/5ML4 OR SUSR A

Max2fills/

annum


MG/5ML4 OR SUSR A

Max2fills/

annum

CefotaximeSodiumFor

Inj500MG4 IJ SOLR A Consumables

CefotaximeSodiumFor

Inj1GM4 IJ SOLR A Consumables

CefoxitinSodiumForInj

1GM4 IJ SOLR A Consumables

CefpodoximeProxetilFor

Susp40MG/5ML4 OR SUSR A

Max2fills/

annum

CefpodoximeProxetilTab

100MG4 OR TABS A

Max2fills/

annum

CeftriaxoneSodiumFor



IVSoln2GM4 IJ SOLR A Consumables

CefuroximeAxetilFor


Max2fills/

annum

CefuroximeSodiumFor


CefuroximeSodiumFor


Cephalexin250MG 4 OR TABS AMax2fills/

annum

Cephalexin500MG 4 OR TABS AMax2fills/

annum

18.1.3 Others Nonelisted


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

18.2. Erythromycin and other macrolides

18.2

Erythromycin

and other

macrolides

ClarithromycinForSusp

125MG/5ML4 OR SUSR A

Max2fills/

annum



Max2fills/

annum

ClarithromycinTab250

MG4 OR TABS A

Max2fills/

annum


MG4 OR TABS A

Max2fills/

annum

ClarithromycinTabSR

24HR500MG4 OR TB24 A

Max2fills/

annum

ErythromycinEstolate

Cap250MG4 OR CAPS A

Max4fills/

annum


Susp125MG/5ML4 OR SUSP A

Max4fills/

annum

RoxithromycinTab150

MG4 OR SUSP A

Max2fills/

annum

18.3. Aminoglycosides Aminoglycosides

18.3Aminoglyco-

sides

GentamicinSulfateInj40

MG/ML4 IJ SOLN A Consumables

18.4. Tetracyclines

18.4 TetracyclinesDoxycyclineHyclateCap

DRParticles50MG4 OR CPEP A

Max4fills/

annum

DoxycyclineHyclateCap

100MG4 OR CAPS A

Max4fills/

annum

MinocyclineHClCap

50MG4 OR CAPS A

Max4fills/

annum

MinocyclineHClCap

100MG4 OR CAPS A

Max4fills/

annum

OxytetracyclineHClCap

250MG4 OR CAPS A

Max4fills/

annum

18.5. Chloramphenicols

18.5Chloram-

phenicols

ChloramphenicolCap

250MG4 OR CAPS A

Max4fills/

annum

ChloramphenicolSusp

125MG/5ML4 OR SUSP A

Max4fills/

annum

18.6. Sulphonamides and combinations

18.6

Sulphona-

mides and

combinations

Sulfamethoxazole-

TrimethoprimIVSoln

400-80MG/5ML

4 IV SOLN A Consumables

Sulfamethoxazole-

TrimethoprimSusp200-

40MG/5ML

4 OR SUSP AMax4fills/

annum

Sulfamethoxazole-

TrimethoprimTab400-80

MG


annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

Sulfamethoxazole-

TrimethoprimTab800-

160MG


annum

18.7 Quinolones

18.7 QuinolonesCiprofloxacinHClTab

250MG4 OR TABS A

Max4fills/

annum

CiprofloxacinHClTab

500MG4 OR TABS A

Max4fills/

annum

18.9. Other anti-bacterial agents

18.9

Other anti-

bacterial

agents

ClindamycinHClCap

150MG4 OR CAPS A

Max2fills/

annum

18.10. Anti-fungal agents

18.10Anti-fungal

agentsFluconazoleCap150MG 4 OR CAPS A

Max2fills/

annum

GriseofulvinMicrosize

Tab125MG4 OR TABS A

Max2fills/

annum


Tab500MG4 OR TABS A

Max2fills/

annum

NystatinSusp100000

Unit/ML4 MT SUSP A

Max2fills/

annum

18.11. Anti-protozoal agents

18.11

Anti-

protozoal

agents

MetronidazoleSusp200

MG/5ML4 OR SUSP A

Max3fills/

annum

MetronidazoleTab200

MG4 OR TABS A

Max3fills/

annum

MetronidazoleTab400

MG4 OR TABS A

Max3fills/

annum

19. ENDOCRINE SYSTEM

19.5. Corticosteroids

19.5Corticoster-

oidsPrednisoneTab5MG 4 OR TABS A

Max3fills/

annum

DisclaimerPleasenotethattheformularywillbereviewedregularlybyclinicalandpharmaceuticaladvisorstoensureitcomplieswiththelatestindustrynormsforthetreatmentoftheseconditions.GEMSreservestherighttochangemedicineontheformularywhenimportantinformationcomestolightthatrequiresustodosoe.g.newfindingregardingthesafetyofadrug.


B: GEMS Ruby, Emerald Value, Emerald and Onyx (REO) dental medicine formulary 2018Key to quantities and limitations

1. “Consumables”meansthemedicationmayonlybeadministratedbyaDSPattherooms.Allinjectablesareconsumablesandclaimsforscripts

giventopatientstocollectfromDSPpharmacieswillberejected.

2. “MaxRx/7days&3Rx/annum”meansascriptfilleduptoamaximumofsevendaysmedicinesupplyandthreeprescriptionsperyearcanbe

claimed.

3. BenefitsformedicinearesubjecttoReferencePricing(MPL)andexclusionlists(MEL).ShouldthecostoftheitemexceedMPL,thepatient

willbeliableforpaymentofthedifferenceincost.Ifthisisthecasepleaseinformthepatientthatitwillbeforhis/herownpersonalaccount.

4. DentaltherapistsmayprescribeasperthelatestgovernmentgazettepublishedbytheDepartmentofHealth.

Please note:ProviderTradeNamesarenotlistedonformulary,allowingforgenericsubstitution,butapplyingReferencePricingandExclusionlists.

MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

1. CENTRAL NERVOUS SYSTEM

1.2 Sedative hypnotics

1.2.1Benzodiaze-

pinesBrotizolamTab0.25MG 5 OR TABS A

MaxRx/5days

every120days

FlunitrazepamTab1MG 6 OR TABS AMaxRx/5days

every120days

FlurazepamHClCap15

MG5 OR CAPS A

MaxRx/5days

every120days

FlurazepamHClCap30

MG5 OR CAPS A

MaxRx/5days

every120days

LoprazolamMeslyateTab

2MG(BaseEquivalent)5 OR TABS A

MaxRx/5days

every120days

LormetazepamCap0.5

MG5 OR CAPS A

MaxRx/5days

every120days

LormetazepamCap1

MG5 OR CAPS A

MaxRx/5days

every120days

LormetazepamCap2

MG5 OR CAPS A

MaxRx/5days

every120days

MidazolamHClInj1MG/

ML(BaseEquivalent)5 IJ SOLN A Consumables

MidazolamHClInj

15MG/3ML(Base

Equivalent)

5 IJ SOLN A Consumables

MidazolamHClInj5MG/

ML(BaseEquivalent)5 IJ SOLN A Consumables

MidazolamHClInj

50MG/10ML(Base

Equivalent)

5 IJ SOLN A Consumables


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

MidazolamInj1MG/ML 5 IJ SOLN A Consumables

MidazolamMaleateTab

15MG5 OR TABS A

MaxRx/5days

every120days

MidazolamMaleateTab

7.5MG5 OR TABS A

MaxRx/5days

every120days

NitrazepamTab5MG 5 OR TABS AMaxRx/5days

every120days

TemazepamCap10MG 5 OR CAPS AMaxRx/5days

every120days

TemazepamCap20MG 5 OR CAPS AMaxRx/5days

every120

TriazolamTab0.125MG 5 OR TABS AMaxRx/5days

every120days

TriazolamTab0.25MG 5 OR TABS AMaxRx/5days

every120days

2. ANAESTHETICS

2.2Local

anaesthetics





LidocaineInj2%w/

Epinephrine-1:800004 IJ SOLN A Consumables

3. ANALGESICS

3.2. Analgesics and antipyretics

3.2

Analgesics

and

antipyretics

AcetaminophenCap500

MG0 OR CAPS A

MaxRx/7days

&3Rx/annum

AcetaminophenEfferTab

500MG0 OR TBEF A

MaxRx/7days

&3Rx/annum

AcetaminophenElixir120

MG/5ML0 OR ELIX A

Max200ml/Rx

&3Rx/annum

AcetaminophenIVSoln

10MG/ML3 IV SOLN A Consumables

AcetaminophenSoln100

MG/ML0 OR SOLN A

Max20ml/Rx&

3Rx/annum

AcetaminophenSoluble

Tab125MG0 OR TBSO A

MaxRx/7days

&3Rx/annum

AcetaminophenSoluble

Tab500MG0 OR TBSO A

MaxRx/7days

&3Rx/annum

AcetaminophenSuppos

125MG2 RE SUPP A

Max1op/

annum

AcetaminophenSuppos

250MG2 RE SUPP A

Max1op/

annum

AcetaminophenSyrup

120MG/5ML0 OR SYRP A

Max200ml/Rx

&3Rx/annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

AcetaminophenTab500

MG0 OR TABS A

MaxRx/7days

&3Rx/annum

AcetaminophenTabCR

650MG1 OR TBCR A

MaxRx/7days

&3Rx/annum

AspirinDispersibleTab

300MG0 OR TBDP A

Max1fill/

annum

AspirinTab300MG 0 OR TABS AMax1fill/

annum

AspirinTab81MG 0 OR TBEC AMax2fills/

annum

IbuprofenSusp100

MG/5ML2 OR SUSP A

Max200ml/Rx

&3Rx/annum

IbuprofenSusp100

MG/5ML2 OR SUSP A

Max200ml/Rx

&3Rx/annum

KetorolacTromethamine

Inj10MG/ML4 IJ SOLN A Consumables


Inj30MG/ML4 IJ SOLN A Consumables


Tab10MG4 OR TABS A

MaxRx/7days

&3Rx/annum

MefenamicAcidCap

250MG3 OR CAPS A

MaxRx/7days

&3Rx/annum

MefenamicAcidSupp

125MG3 RE SUPP A

Max1op/

annum

MefenamicAcidSusp50

MG/5ML3 OR SUSP A

Max200ml/Rx

&3Rx/annum

MefenamicAcidTab500

MG3 OR TABS A

MaxRx/7days

&3Rx/annum

3.3. Combination Analgesics

3.3Combination

analgesics

Acetaminophenw/

Codeine&VitaminsTab

500-10-50MG


&3Rx/annum

Acetaminophenw/

CodeineCap320-8MG1 OR TABS A

MaxRx/7days

&3Rx/annum

Acetaminophenw/

CodeineEfferTab500-8

MG

2 OR TBEF AMaxRx/7days

&3Rx/annum

Acetaminophenw/

CodeineSyrup120-5

MG/5ML


&3Rx/annum

Acetaminophenw/

CodeineSyrup150-4

MG/5ML


&3Rx/annum

Acetaminophenw/

CodeineTab500-10MG1 OR TABS A

MaxRx/7days

&3Rx/annum

Acetaminophenw/


MaxRx/7days

&3Rx/annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

Acetaminophenw/


MaxRx/7days

&3Rx/annum

Acetaminophen-

Diphenhydramine-Caff-

CodTab400-5-50-10

MG


&3Rx/annum

Acetaminophen-

Doxylamine-Caff-Cod

EfferTab450-5-50-10

MG

2 OR TBEF AMaxRx/7days

&3Rx/annum

Acetaminophen-

Doxylamine-Caffeine-

CodeineCap450-5-30-

10MG


&3Rx/annum

Acetaminophen-


CodeineTab450-5-45-

10MG


&3Rx/annum

Acetaminophen-


CodeineTab450-5-50-

10MG


&3Rx/annum

Acetaminophen-


Cap200-150-30-10MG


&3Rx/annum

Acetaminophen-


Cap320-150-48-8MG


&3Rx/annum

Acetaminophen-


Tab200-150-30-10MG


&3Rx/annum

Acetaminophen-


Tab320-150-32-8MG


&3Rx/annum

Acetaminophen-

Meprobamate-Codeine

Cap400-200-8MG


&3Rx/annum

Acetaminophen-

Meprobamate-Codeine

Tab500-125-10MG


&3Rx/annum

Acetaminophen-

Phenyltoloxamine-Caff-

CodTab400-12-32-8

MG


&3Rx/annum

Acetaminophen-

Promethazinew/

CodeineSyrup120-6.5-5

MG/5ML


&3Rx/annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

Acetaminophen-

Promethazinew/Codeine

Syrup120-7-5MG/5ML

2 OR SYRP AMaxRx/7days

&3Rx/annum

APAP-Aspirin-Caffeine-

CitratedCaffPack276-

553-8-33MG

0 OR PACK AMaxRx/7days

&3Rx/annum

APAP-Diphenhydramine-

PB-Caff-CodTab400-5-

8-50-10MG


&3Rx/annum

APAP-NaSalicylate-

Aloin-BuchuTab97.19-

48.59-0.65-32.4MG


&3Rx/annum

ASA-APAP-


Tab200-200-150-30-10

MG


&3Rx/annum

Aspirinw/Codeine

DispersibleTab500-8

MG

2 OR TBDP AMaxRx/7days

&3Rx/annum

Aspirin-Acetaminophen

w/CodeineTab250-

250-10MG


&3Rx/annum

Aspirin-Acetaminophen-

CaffeinePowdPack

453.6-324-64.8MG

0 OR POWD AMaxRx/7days

&3Rx/annum


CaffeineTab226-160-32

MG


&3Rx/annum



MG


&3Rx/annum



MG


&3Rx/annum

Aspirin-CaffeineTab325-

22MG0 OR TABS A

MaxRx/7days

&3Rx/annum


22.7MG0 OR TABS A

MaxRx/7days

&3Rx/annum


24MG0 OR TABS A

MaxRx/7days

&3Rx/annum


32MG0 OR TABS A

MaxRx/7days

&3Rx/annum

Ibuprofen-

AcetaminophenCap

200-250MG


&3Rx/annum

Ibuprofen-

AcetaminophenSusp

100-125MG/5ML

2 OR SUSP AMax100ml/Rx

&3Rx/annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

Ibuprofen-

AcetaminophenTab

200-350MG


&3Rx/annum

Ibuprofen-

AcetaminophenTab

400-325MG


&3Rx/annum

Ibuprofen-

Acetaminophen-Codeine

Cap200-250-10MG


&3Rx/annum

Ibuprofen-


Susp200-250-10

MG/10ML

3 OR SUSP AMax100ml/Rx

&3Rx/annum

Ibuprofen-


Tab200-350-10MG


&3Rx/annum

Ibuprofen-CodeineTab

200-10MG2 OR TABS A

MaxRx/7days

&3Rx/annum

Ibuprofen-CodeineTab

200-12.5MG2 OR TABS A

MaxRx/7days

&3Rx/annum

Mephenesin-

AcetaminophenTab

150-500MG


&3Rx/annum

Orphenadrinew/APAP

Tab35-450MG2 OR TABS A

MaxRx/7days

&3Rx/annum

Tramadol-Acetaminophen

Tab37.5-325MG5 OR TABS A

MaxRx/7days

&3Rx/annum

4. MUSCULO-SKELETAL AGENTS

4.1 Non-steroidal anti-inflammatory agents

4.1.1COX

inhibitors

DiclofenacPotassium

Tab12.5MG2 OR TABS A

MaxRx/5days

&2Rx/annum

DiclofenacPotassium

Tab50MG2 OR TABS A

MaxRx/5days

&2Rx/annum

DiclofenacPotassium

TabDisp50MG3 OR PACK A

MaxRx/5days

&2Rx/annum

DiclofenacSodiumCap

SR24HR100MG3 OR CP24 A

MaxRx/5days

&2Rx/annum

DiclofenacSodiumCap

SR24HR75MG3 OR CP24 A

MaxRx/5days

&2Rx/annum

DiclofenacSodiumIMInj

Soln25MG/ML3 IJ SOLN A Consumables

DiclofenacSodium

Suppos100MG3 RE SUPPS A

Max1op/Rx&

2Rx/annum

DiclofenacSodium

Suppos12.5MG3 RE SUPPS A

Max1op/Rx&

2Rx/annum

DiclofenacSodium

Suppos25MG3 RE SUPPS A

Max1op/Rx&

2Rx/annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

DiclofenacSodiumSusp

15MG/ML3 OR SUSP A Consumables

DiclofenacSodiumTab

DelayedRelease25MG2 OR TBEC A

MaxRx/5days

&2Rx/annum

DiclofenacSodiumTab

DelayedRelease50MG2 OR TBEC A

MaxRx/5days

&2Rx/annum

DiclofenacSodiumTab

Disp50MG3 OR TBDP A

MaxRx/5days

&2Rx/annum

DiclofenacSodiumTab

SR24HR100MG3 OR TB24 A

MaxRx/5days

&2Rx/annum

DiclofenacSodiumTab

SR24HR75MG3 OR TB24 A

MaxRx/5days

&2Rx/annum

Diclofenacw/Misoprostol

ECTab50-0.2MG4 OR TABS A

MaxRx/5days

&2Rx/annum

Diclofenacw/Misoprostol

TabCR75-0.2MG4 OR TABS A

MaxRx/5days

&2Rx/annum

IbuprofenCap200MG 1 OR CAPS AMaxRx/5days

&2Rx/annum

IbuprofenCap400MG 1 OR CAPS AMaxRx/5days

&2Rx/annum

IbuprofenLysineIV

Soln10MG/2ML(Base

Equivalent)


IbuprofenTab200MG 3 OR TABS AMaxRx/5days

&2Rx/annum


&2Rx/annum


&2Rx/annum

IbuprofenTabCR800

MG3 OR TBCR A

MaxRx/5days

&2Rx/annum

IndomethacinCap25

MG3 OR CAPS A

MaxRx/5days

&2Rx/annum

IndomethacinCap50

MG3 OR CAPS A

MaxRx/5days

&2Rx/annum

IndomethacinSuppos

100MG3 RE SUPP A

Max1op/Rx&

2Rx/annum

KetoprofenCapSR

24HR200MG3 OR CP24 A

MaxRx/5days

&2Rx/annum

LornoxicamInj4MG/ML 3 IJ SOLN A Consumables

LornoxicamTab4MG 3 OR TABS AMaxRx/5days

&2Rx/annum

LornoxicamTab8MG 3 OR TABS AMaxRx/5days

&2Rx/annum

NaproxenSodiumCap

220MG2 OR CAPS A

MaxRx/5days

&2Rx/annum

NaproxenSodiumTab

275MG3 OR TABS A

MaxRx/5days

&2Rx/annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

NaproxenSodiumTab

550MG3 OR TABS A

MaxRx/5days

&2Rx/annum

NaproxenSuppos500

MG3 RE SUPPS A

Max1op/Rx&

2Rx/annum

NaproxenTab250MG 3 OR TABS AMaxRx/5days

&2Rx/annum

NaproxenTab500MG 3 OR TABS AMaxRx/5days

&2Rx/annum

NaproxenTabEC250

MG3 OR TBEC A

MaxRx/5days

&2Rx/annum

NaproxenTabEC500

MG3 OR TBEC A

MaxRx/5days

&2Rx/annum

PiroxicamBetadexTab

20MG(BaseEquiv)3 OR TABS A

MaxRx/5days

&2Rx/annum

PiroxicamCap10MG 2 OR TABS AMaxRx/5days

&2Rx/annum

PiroxicamCap20MG 2 OR TABS AMaxRx/5days

&2Rx/annum

PiroxicamTabDisp20

MG3 OR TBDP A

MaxRx/5days

&2Rx/annum

SulindacTab200MG 3 OR TABS AMaxRx/5days

&2Rx/annum

4.1.2

Selective

COX2

Inhibitors

MeloxicamIMInj10MG/

ML3 IM SOLN A Consumables

MeloxicamTab15MG 3 OR TABS AMaxRx/5days

&2Rx/annum

MeloxicamTab7.5MG 3 OR TABS AMaxRx/5days

&2Rx/annum

11. EAR, NOSE AND THROAT

11.3 Mouth and throat preparations

11.3

Mouth

and throat

preparations

BenzocaineLozenge

10MG1 MT LOZG A

Max20/Rx&4

Rx/annum

Benzocaine-

CetylpyridiniumSoln

1-0.1%

1 MT SOLN AMax1op/

annum

Benzocaine-


Soln

1 MT SOLN AMax200ml/

annum

BenzydamineHClLozg

3MG1 MT LOZG A

Max20/Rx&4

Rx/annum

BenzydamineHClSoln

0.15%1 MT SOLN A

Max1op/Rx&

2Rx/annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

Benzydamine-

CetylpyridniumLozg

3-1.33MG

1 MT LOZG AMax24/Rx&4

Rx/annum

Benzydamine-


Soln0.15-0.12%

1 MT SOLN AMax1op/Rx&

2Rx/annum

CetylpyridiniumChloride

Liquid0.05%0 MT SOLN A

Max200ml/

annum

Cetylpyridinium-

BenzocaineLozenge

1.5-10MG


Rx/annum

Cetylpyridinium-

BenzocaineLozenge

2-10MG


Rx/annum


Soln0.2%0 MT SOLN A

Max200ml/

annum

DequaliniumChloride-

LidocaineMouthPaint

40-175MG/10ML

1 MT LIQD AMax1op/

annum

Dibucaine-Benzocaine-

Cetylpyridinium-Benzyl

AlcoholSoln

1 MT SOLN AMax200ml/

annum

FlurbiprofenLozenge

8.75MG0 MT LOZG A

Max1op/Rx&

2Rx/annum

HexetidineSoln0.1% 0 MT SOLN AMax200ml/

annum

MentholLozenge1MG 0 MT LOZG AMax20/Rx&4

Rx/annum

MiconazoleGel2%

(Mouth-Throat)2 MT GEL A

Max1op/

annum

OrabasePaste 0 MT PSTE AMax1op/

annum

PhenolSoln0.5% 0 MT SOLN AMax1op/

annum

Povidone-Iodine

Mouthwash1%0 MT SOLN A

Max200ml/

annum

TetracaineHClOintment

0.5%1 MT OINT A

Max1op/

annum

ZincGluconatew/

VitaminCLozenge25-50

MG


Rx/annum

18. ANTI-MICROBIALS

18.1. Beta-lactams

18.1.1 Penicillins

Amoxicillin&K

ClavulanateForIVSoln

1000-200MG

4 IV SOLR A Consumables


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

Amoxicillin&K

ClavulanateForIVSoln

500-100MG


Amoxicillin&K

ClavulanateForSusp

125-31.25MG/5ML


annum

Amoxicillin&K

ClavulanateForSusp

200-28.5MG/5ML


annum

Amoxicillin&K

ClavulanateForSusp

250-62.5MG/5ML


annum

Amoxicillin&K

ClavulanateForSusp

400-57MG/5ML


annum

Amoxicillin&K

ClavulanateForSusp

600-42.9MG/5ML


annum

Amoxicillin&K


MG


annum

Amoxicillin&K


MG


annum

Amoxicillin&K


MG


annum

Amoxicillin&K

ClavulanateTabSR

12HR1000-62.5MG

4 OR TB12 AMax4fills/

annum


Cap250MG4 OR CAPS A

Max4fills/

annum


Cap500MG4 OR CAPS A

Max4fills/

annum


ForSusp100MG/ML4 OR SUSR A

Max4fills/

annum



Max4fills/

annum



Max4fills/

annum

Amoxicillin-FloxacillinCap


Max4fills/

annum

Amoxicillin-FloxacillinFor

Susp125-125MG/5ML4 OR SUSP A

Max4fills/

annum

AmpicillinCap250MG 4 OR CAPS AMax4fills/

annum

AmpicillinForSusp125

MG/5ML4 OR SUSR A

Max4fills/

annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

AmpicillinSodiumForInj

250MG4 IJ SOLR A Consumables

AmpicillinSodiumForInj


Ampicillin-CloxacillinCap


Max4fills/

annum


Inj125-125MG4 IJ SOLR A Consumables






Susp125-125MG/5ML4 OR SUSR A

Max4fills/

annum


250MG4 OR CAPS A

Max4fills/

annum


500MG4 OR CAPS A

Max4fills/

annum

CloxacillinSodiumForInj


CloxacillinSodiumForInj


FloxacillinSodiumCap

250MG4 OR CAPS A

Max4fills/

annum



1200000Unit




2400000Unit


PenicillinGProcaine

IntramuscularSusp

300000Unit/ML


PenicillinGSodiumFor

Inj1000000Unit4 IJ SUSR A Consumables

PenicillinGSodiumFor

Inj5000000Unit4 IJ SUSR A Consumables

PenicillinVPotassiumFor

Soln125MG/5ML4 OR SOLR A

Max4fills/

annum

PenicillinVPotassium

Tab250MG4 OR TABS A

Max4fills/

annum

PiperacillinSodium-

TazobactamSodiumFor

Inj4-0.5GM


18.1.2Cephalospor-

ins

CefaclorForSusp187

MG/5ML4 OR SUSR A

Max2fills/

annum

CefaclorForSusp375

MG/5ML4 OR SUSR A

Max2fills/

annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

CefaclorMonohydrate

TabSR12HR375MG4 OR TB12 A

Max2fills/

annum

CefadroxilCap500MG 4 OR CAPS AMax2fills/

annum

CefadroxilEfferTab250

MG4 OR TBEF A

Max2fills/

annum


MG/5ML4 OR SUSR A

Max2fills/

annum


MG/5ML4 OR SUSR A

Max2fills/

annum

CefazolinSodiumForInj


CefazolinSodiumForInj


CefazolinSodiumForIV

Soln1GM4 IV SOLR A Consumables

CefepimeHClForInj1

GM4 IJ SOLN A Consumables

CefepimeHClForInj2

GM4 IJ SOLN A Consumables

CefepimeHClForInj

500MG4 IJ SOLN A Consumables

CefiximeTab400MG 4 OR TABS AMax2fills/

annum

CefotaximeSodiumFor


CefotaximeSodiumFor


CefoxitinSodiumForInj


CefpodoximeProxetilFor


Max2fills/

annum


100MG4 OR TABS A

Max2fills/

annum


200MG4 OR TABS A

Max2fills/

annum

CefprozilForSusp125

MG/5ML4 OR SUSR A

Max2fills/

annum

CefprozilForSusp250

MG/5ML4 OR SUSR A

Max2fills/

annum

CefprozilTab250MG 4 OR TABS AMax2fills/

annum

CefprozilTab500MG 4 OR TABS AMax2fills/

annum

CeftazidimeForInj1GM 4 IJ SOLR A Consumables

CeftazidimeForInj2GM 4 IJ SOLR A Consumables

CeftazidimeForInj500

MG4 IJ SOLR A Consumables


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS










IVSoln2GM4 IJ SOLR A Consumables

CefuroximeAxetilFor


Max2fills/

annum

CefuroximeAxetilTab

125MG4 OR TABS A

Max2fills/

annum

CefuroximeAxetilTab

250MG4 OR TABS A

Max2fills/

annum

CefuroximeAxetilTab

500MG4 OR TABS A

Max2fills/

annum

CefuroximeSodiumFor

Inj1.5GM4 IJ SOLR A Consumables

CefuroximeSodiumFor


CefuroximeSodiumFor


CephalexinCap250MG 4 OR CAPS AMax2fills/

annum

CephalexinForSusp125

MG/5ML4 OR SUSR A

Max2fills/

annum

CephalexinForSusp250

MG/5ML4 OR SUSR A

Max2fills/

annum

CephalexinTab250MG 4 OR TABS AMax2fills/

annum

CephalexinTab500MG 4 OR TABS AMax2fills/

annum

CephradineCap250MG 4 OR CAPS AMax2fills/

annum

CephradineForInj1GM 4 IJ SOLR A Consumables

CephradineForInj500


Imipenem-Cilastatin

IntravenousForSoln500

MG

4 IV INJ A Consumables

18.1.3 Others Nonelisted

18.2. Erythromycin and other macrolides

18.2

Erythromycin

and other

macrolides

AzithromycinCap250

MG4 OR CAPS A

Max2fills/

annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

AzithromycinExtended

ReleaseForOralSusp

2GM

4 OR GRAN AMax2fills/

annum

AzithromycinForSusp


Max2fills/

annum

AzithromycinIVForSoln

500MG4 IV SOLR A Consumables

AzithromycinTab500

MG4 OR TABS A

Max2fills/

annum

ClarithromycinForIV

Soln500MG4 IV SOLR A Consumables



Max2fills/

annum



Max2fills/

annum


MG4 OR TABS A

Max2fills/

annum


MG4 OR TABS A

Max2fills/

annum

ClarithromycinTabSR

24HR500MG4 OR TB24 A

Max2fills/

annum


Cap250MG4 OR CAPS A

Max4fills/

annum



Max4fills/

annum



Max4fills/

annum

Erythromycin

LactobionateForInj1000

MG


ErythromycinStearate

Cap250MG4 OR CAPS A

Max4fills/

annum

ErythromycinStearate

Tab250MG4 OR TABS A

Max4fills/

annum

RoxithromycinTab150

MG4 OR TABS A

Max2fills/

annum

RoxithromycinTab300

MG4 OR TABS A

Max2fills/

annum

TelithromycinTab400

MG4 OR TABS A

Max2fills/

annum

18.3. Aminoglycosides

18.3Aminoglyco-

sides





18.4. Tetracyclines

18.4 TetracyclinesDoxycyclineHyclateCap

100MG4 OR CAPS A

Max4fills/

annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS


50MG4 OR CAPS A

Max4fills/

annum


DRParticles200MG4 OR CPEP A

Max4fills/

annum

DoxycyclineHyclateTab

100MG4 OR TABS A

Max4fills/

annum

DoxycyclineMonohydrate

Tab100MG4 OR TABS A

Max4fills/

annum

LymecyclineCap150

MG4 OR CAPS A

Max4fills/

annum

LymecyclineCap300

MG4 OR CAPS A

Max4fills/

annum

MinocyclineHClCap

100MG4 OR CAPS A

Max4fills/

annum

MinocyclineHClCap

50MG4 OR CAPS A

Max4fills/

annum

MinocyclineHClTab50

MG4 OR TABS A

Max4fills/

annum

OxytetracyclineHClCap

250MG4 OR CAPS A

Max4fills/

annum

Tetracycline250MG-

Nystatin250,000Unitw/

VitaminsCap

4 OR CAPS AMax4fills/

annum

18.5. Chloramphenicols

18.5Chloram-

phenicols

ChloramphenicolCap

250MG4 OR CAPS A

Max4fills/

annum

ChloramphenicolSodium

SuccinateForIVInj1GM4 IV SOLR A Consumables

ChloramphenicolSusp


Max4fills/

annum

18.6. Sulphonamides and combinations

18.6

Sulphona-

mides and

combinations

Sulfamethoxazole-

TrimethoprimIVSoln

400-80MG/5ML


Sulfamethoxazole-

TrimethoprimSusp200-

40MG/5ML


annum

Sulfamethoxazole-

TrimethoprimTab400-80

MG


annum

Sulfamethoxazole-

TrimethoprimTab800-

160MG


annum

18.7 Quinolones

18.7 Quinolones

CiprofloxacinForOral

Susp250MG/5ML(5%)

(5GM/100ML)


annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

CiprofloxacinHClTab


Max4fills/

annum

CiprofloxacinHClTab


Max4fills/

annum

CiprofloxacinHClTab


Max4fills/

annum

CiprofloxacinLactateIV

Soln2MG/ML4 IV SOLN A Consumables

Ciprofloxacin-

CiprofloxacinHClTabSR

24HR1000MG(BaseEq)


annum

Ciprofloxacin-

CiprofloxacinHClTabSR

24HR500MG(BaseEq)


annum

GemifloxacinMesylate

Tab320MG(BaseEquiv)4 OR TABS A

Max4fills/

annum

LevofloxacinIVSoln5

MG/ML4 IV SOLN A Consumables

LevofloxacinTab250MG 4 OR TABS AMax4fills/

annum


annum


annum

MoxifloxacinHCl400

MG/250MLinSodium

Chloride0.8%Inj


MoxifloxacinHClTab400

MG(BaseEquiv)4 OR TABS A

Max4fills/

annum

NorfloxacinTab400MG 4 OR TABS AMax4fills/

annum

OfloxacinIVSoln200

MG/100ML4 IV SOLN A Consumables

OfloxacinTab200MG 4 OR TABS AMax4fills/

annum

OfloxacinTab400MG 4 OR TABS AMax4fills/

annum

18.9. Other anti-bacterial agents

18.9

Other anti-

bacterial

agents

ClindamycinHClCap

150MG4 OR CAPS A

Max2fills/

annum

ClindamycinPhosphate

Inj600MG/4ML4 IJ SOLN A Consumables

FusidateSodiumIVFor

Inj500MG4 IV SOLR A Consumables

FusidateSodiumSusp


Max2fills/

annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

FusidateSodiumTab

250MG4 OR TABS A

Max2fills/

annum

LincomycinHClInj300

MG/ML4 IM SOLN A Consumables

LinezolidForSusp100

MG/5ML4 OR SUSP A

Max2fills/

annum

LinezolidIVSoln2MG/

ML4 IV SOLN A Consumables

LinezolidTab600MG 4 OR TABS AMax2fills/

annum

TeicoplaninForInj200


TeicoplaninForInj400


TigecyclineForIVSoln


VancomycinHClForInj


VancomycinHClForInj


18.10. Anti-fungal agents

18.10Anti-fungal

agents

AmphotericinBForInj


AmphotericinB

LiposomeIVForSusp

50MG


CaspofunginAcetateFor

IVSoln50MG4 IV SOLR A Consumables

CaspofunginAcetateFor

IVSoln70MG4 IV SOLR A Consumables

ClotrimazoleTroche10

MG4 MT LOZG A

Max2fills/

annum

FluconazoleCap150MG 4 OR CAPS AMax2fills/

annum

FluconazoleCap200MG 4 OR CAPS AMax1fill/

annum

FluconazoleCap50MG 4 OR CAPS AMax1fill/

annum

FluconazoleForSusp10

MG/ML4 OR SUSP A

Max100ml/RX

&2RX/annum

FluconazoleForSusp40

MG/ML4 OR SUSP A

Max100ml/RX

&2RX/annum

FluconazoleInj2MG/ML 4 IV SOLN A Consumables


Tab125MG4 OR TABS A

Max2fills/

annum


Tab500MG4 OR TABS A

Max2fills/

annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

ItraconazoleCap100MG 4 OR CAPS AMax2fills/

annum

ItraconazoleOralSoln10

MG/ML4 OR SOLN A

Max2fills/

annum

KetoconazoleTab200

MG4 OR TABS A

Max2fills/

annum

NystatinSusp100000

Unit/ML4 MT SUSP A

Max2fills/

annum

PosaconazoleSusp40

MG/ML4 OR SUSP A

Max2fills/

annum

18.11. Anti-protozoal agents

18.11

Anti-

protozoal

agents

MetronidazoleCap200

MG4 OR CAPS A

Max3fills/

annum

MetronidazoleIVSoln5

MG/ML4 IV SOLN A Consumables

MetronidazoleSupp1

GM4 RE SUPP A

Max3fills/

annum

MetronidazoleSupp500

MG4 RE SUPP A

Max3fills/

annum

MetronidazoleSusp200

MG/5ML4 OR SUSP A

Max3fills/

annum

MetronidazoleTab200

MG4 OR TABS A

Max3fills/

annum

MetronidazoleTab400

MG4 OR TABS A

Max3fills/

annum

19. ENDOCRINE SYSTEM

19.5. Corticosteroids

19.5Corticoster-

oids

Betamethasone

DipropionateInj5MG/ML4 INJ SOLN A Consumables

MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

BetamethasoneSod

Phosphate&AcetateInj

Susp6(3-3)MG/ML

4 INJ SOLN A Consumables

BetamethasoneSodium

PhosphateInj4MG/ML

(3MG/MLBaseEq)

4 INJ SOLN A Consumables

BetamethasoneSyrup

0.6MG/5ML4 OR SYRP A

Max3fills/

annum

BetamethasoneTab0.5

MG4 OR TABS A

Max3fills/

annum

Betamethasone-

Dexchlorpheniramine

Syrup0.25-2MG/5ML

4 OR SYRP AMax3fills/

annum


MIMSMIMS


ROUTE

OF

ADMIN

DOSAGE

FORMACUTE

QUANTITIES

AND

LIMITATIONS

Betamethasone-

DexchlorpheniramineTab

0.25-2MG


annum

DexamethasoneSodium

PhosphateInj4MG/ML4 INJ SOLN A Consumables

FludrocortisoneAcetate

Tab0.1MG4 OR TABS A

Max3fills/

annum

HydrocortisoneSodium

SuccinateForInj100MG4 IJ SOLR A Consumables

HydrocortisoneSodium

SuccinateForInj500MG4 IJ SOLR A Consumables

Methylprednisolone

AcetateInjSusp40MG/

ML

4 IM SUSP A Consumables

Methylprednisolone

SodiumSuccinateForInj

125MG

4 IJ SOLR A Consumables

Methylprednisolone

SodiumSuccinateForInj

40MG

4 IJ SOLR A Consumables

Methylprednisolone

SodiumSuccinateForIV

Soln1000MG


MethylprednisoloneTab

16MG4 OR TABS A

Max3fills/

annum

MethylprednisoloneTab

4MG4 OR TABS A

Max3fills/

annum

PrednisoloneSyrup15

MG/5ML(USPSolution

Equivalent)

4 OR SYRP AMax3fills/

annum

PrednisoneConc5MG/

ML4 OR SOLN A

Max3fills/

annum

PrednisoneTab20MG 4 OR TABS AMax3fills/

annum


annum


annum

DisclaimerPleasenotethattheformularywillbereviewedregularlybyclinicalandpharmaceuticaladvisorstoensureitcomplieswiththelatestindustrynormsforthetreatmentoftheseconditions.GEMSreservestherighttochangemedicineontheformularywhenimportantinformationcomestolightthatrequiresustodosoe.g.newfindingregardingthesafetyofadrug.


Pre-authorisation

Claim procedures

• Inallcaseswherepre-authorisationarerequiredasspecifiedearlierand

peroptioninthisguidepleasecompletetherelevantsectionsofthe

“DentalReportforRegistration,Pre-notificationandPre-authorisation

Form”andsubmittotheSchemepriortothecommencementof

treatment.

• Should you be unsure as towhether pre-authorisation is

needed rather contact the call centre on 0860 436 777 to

prevent rejection of the patient’s account by the Scheme.

Note:Toothchartingontheformisnotnecessaryforpre-authorisation

ortreatmentplanpurposes(chartingonlyneedstobecompletedat

thepatient’sFIRSTvisittothepracticeinassociationwithcode8101).

• Orthodontic treatment:Please submit a pre-authorisation form

and treatment planwhich should include the diagnosis and

paymentquotationforapprovalpriortotreatmenttotheSchemeat

[email protected].

• Periodontal treatment: Please complete the “Periodontal

TreatmentPre-authorisationForm”whichcanbedownloadedfrom

www.gems.gov.zaandsubmittotheScheme.

Required information on claims

• Mainmemberdetailssuchasmembershipnumber,option,name,

contactdetails

• Patientdetails,includingdateofbirth,namesandidentitynumber

• Providerdetail:ValidBHFpracticenumber,name,contactdetails

• Diagnosisandsummaryofmedicalproceduresperformed,medicine

dispensed,otheritemsdispensedtopatient

• Relevanttariffcodes

• Completelistofindividuallaboratorycodes

• Associatedcosts

Rejection on claims

• Ifthedetailsareincompletetheclaimwillberejected.

• Theclinicalandlaboratorycodesaretobesubmittedtogetherensuring

correspondingservicedates,detailsofcodesusedcorrespondwith

eachotherandauthorisationnumbersattachedforlaboratorycodes

whereclinicalcodesrequirepre-authorisation.

• Self-claiming laboratoriesmay not submit their claimwithout

confirmationwiththedentistthattheclinicaldeliverywascompleted.

• Anyotherproceduresdoneoutsidethescopeofbenefitwillnotbe

paid.

• Allclaimsfromnon-networkdentistsonSapphireandBeryloptions

exceptemergencyconsultations(limitedtooneeventperyear)will

notbefunded.

• Allclaimsrequiringpre-authorisation. Ifnovalidpre-authorisation

exists,theclaimwillberejected.

Six

Seven


• Pleaseensureavailablebenefitcodesandtariffvalueisverifiedwith

theSchemewhereunsure.

• Thedentalprovider is required to verifymembershipdetailsand

confirmtheidentityofthepatient.

• TheSchemewillnotberesponsible foranypaymentofservices

excludedinaccordancewithSchemeormanagedcarerules.

• Memberswillbeheldfullyliableforanyclaimsincurredonbenefits

fallingoutsidethebenefitschedule.

• Benefitconfirmationviapre-authorisationisrequiredwhereindicated.

EightMember verification and validation


Exclusions

Ex gratia

Pleaserefertothesummaryofbenefits,detailedprocedurebenefitlists/

schedulesandgeneralexclusionsearlier in thismanualpertaining to

eachoptiontoensureawarenessofbenefitsallowed,exclusionsand

managedcarerulesthatapply(e.g.pre-authorisation,numberofannual

events,agerulesetc.)

In instanceswhere treatment isperformedwhereexclusionsexistor

thepatient’sbenefitshavingbeenexceeded,thepatientwillbeliable

toself-fundsuch–pleaseensurethe“PatientConsentForm”forlimits

exceeded(12.3)iscompletedbythepatientandkeptonfileatthepractice.

ApplicationforanexgratiaconsiderationintheeventofbenefitsnotcoveredmaybelodgedwiththeSchemeinaccordancewithSchemerules.

Nine

Ten


Forms

Example: Dental report for registration, pre-notification and pre-authorisation(TheformsareavailableontheGEMSwebsiteatwww.gems.gov.za.Emailthecompletedformtoenquiries@gems.gov.zaorfaxto0861004367.)

Eleven

Dental report forregistration, pre-notification and pre-authorisation

Dental practitioner/therapist/specialist

Network provider code Practice no

Tel no (W) ( ) Fax no ( ) Cell phone no

Email

Please complete relevant sections

To be completed by dental service provider for Sapphire, Beryl, Ruby, Emerald Value, Emerald and Onyx options.

Section A: Dental practitioner/dental therapist/dental specialist

Main member initials Surname

Membership no

Patient full names

Dependant code Patient birthdate

Only report significant medical conditions, allergies, prosthesis and/or medicine as recorded on your practice medical history questionnaire.

Section B: Member and patient details

Section C: Medical history

M M Y Y Y YD D

Report carious and/or fractured teeth by number and surface/s:

NOTE: This dental chart must ONLY be completed at the first visit of a patient to the practice after 1 January 2013.

Please record the current dental status of all teeth on the chart above by colouring/highlighting the applicable tooth surfaces on the chart and indicating in the blocks adjacent to any specific tooth the types of restorations, prosthesis and/or conditions present as per abbreviation legend above: (refer to Dental Provider Manual for detailed sample on completion).

Section D: Dental charting: List current status of patient’s dentition

A = Amalgam restorationP = Porcelain restoration

MC = Metal crownRCT = Root canal treatment

U = Unerupted or impacted toothPO = Pontic

RIGHT

R = Resin restorationPC = Porcelain crownM = Metal restoration (inlay or onlay)

X = Extracted toothI = ImplantD = Denture

LEFT

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

55 54 53 52 51 61 62 63 64 65

85 84 83 82 81 71 72 73 74 75

1 of 2


Practice no

Section E: Dental practitioner/dental therapist/dental specialist details

Section F: Intra- and extra-oral examination

Please note any significant findings:

Soft tissue

Hard tissue

Periodontal tissue

Please attach a treatment plan and detailed quotation with all relevant treatment codes, tooth numbers, dental technician costs etc. (A printed copy generated by your practice management software is preferred.)

Please note: Application forms are to be completed in full and submitted to the following fax number: 0861 004 367 or email [email protected]. Should benefits be approved, a letter of authorisation will be faxed/emailed to the attending dental practitioner/specialist within two (2) working days of receipt of this form and approval of benefits.

Section G: Treatment plan and quotation

Section H: Pre-authorisation and pre-notification request procedure

2 of 2

3260_LOGOGISTICS


Example: Dental report for periodontal pre-authorisation(TheformsareavailableontheGEMSwebsiteatwww.gems.gov.za.Emailthecompletedformtoenquiries@gems.gov.zaorfaxto0861004367.)

Dental report forperiodontal pre-authorisation


Network provider code Practice no

Tel no (W) ( ) Fax no ( ) Cell phone no

Email

Section A: Dental practitioner/dental therapist/dental specialist

0 Normal+1 Facial-Lingual-IMM.++2 Mecial-Distal-IMM.++3 Both- 1 and + 2

Light

Moderate

Heavy

Mobility grades (indicate in blocks above) Calculus accumulation

Main member initials Surname

Membership no

Patient full names

Dependant code Patient birthdate

(Denote tooth number, where applicable):

Section B: Member and patient details

Section C: Periodontal evaluation

Localised

Recession

Fibrosis

Mucogingival defect

Firm, resilient

Hyperplasia

Cratering

Suppuration

Generalised

Haemorrhage on probing

Edema

Gingival condition:

Stable & non-contributory

Muscle tenderness

Fremitus

I Gingivitus

Favourable

Missing teeth

Bruxism

Centric interference

II Early

Guarded

Clenching

No replacement

Food impaction

III Moderate

Poor

Malpositioned

Jaw opening deviation

IV Advanced

Hopeless

Occlusion:

Diagnosis:

Diagnosis:

Localised

Generalised

Mild

Moderate

SevereRadiographic examination:

M M Y Y Y YD D

Mobility

Mobility

Please attach a detailed quotation with all relevant treatment codes, tooth numbers, dental technician costs etc. (a printed copy generated by your practice management software is preferred).

Please note: Application forms are to be completed in full and submitted to the following fax number: 0861 00 4367 or email [email protected]. Should benefits be approved, a letter of authorisation will be faxed/emailed to the attending dental practitioner/specialist within two (2) working days of receipt of this form and approval of benefits.

Section D: Quotation

Section E: Pre-authorisation request procedure

To be completed by Dental Service Provider for Ruby, Emerald Value, Emerald and Onyx options.

3262_LOGOGISTICS


Example: Patient consent form(TheformsareavailableontheGEMSwebsiteatwww.gems.gov.za.Emailthecompletedformtoenquiries@gems.gov.zaorfaxto0861004367.)


Working towards a healthier you

CONTACT GEMS

Call0860004367

Fax 0861004367

[email protected]

Address

PrivateBagx782,CapeTown,8000

www.gems.gov.za

experience the gems difference

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