Gems Medical Aid

GEMS medical aid has a network of healthcare service providers consisting of general practitioners (GP), pharmacies, dentists and optometrists who have promised to deliver quality healthcare to GEMS members. Healthcare service providers on the GEMS Network have agreed to provide quality healthcare to GEMS members at Scheme rates. This means you will not have to pay any amounts above the set amount we have agreed with them. All Network healthcare service providers who are part of the Sapphire and Beryl Network will display a GEMS Network logo/sticker on their window or door, making it easy for you to identify them.

GEMS Medical Aid Network

Members on the Sapphire option need to keep the following in mind:

Please ensure that your GP, optometrist or dentist is on the GEMS Network before you visit them. This will ensure that you do not have to pay out of your pocket for the appointment or treatment.

Visits to a specialist or allied healthcare provider (such as a physiotherapist or speech therapist) need to be referred by your Network GP, who will obtain authorisation from the GEMS Call Centre.

Pathology and radiology tests (blood tests and x-rays) must be in line with the GEMS formulary (list of approved tests or services) for Sapphire and Beryl and also require referral from your Network GP.

GEMS will be introducing a pathology and radiology claims validation service to assist in ensuring that these claims are managed appropriately when you claim.

GEMS Medical Aid Beryl Option

Please ensure that your GP, optometrist or dentist is on the GEMS Network before you visit them. This will ensure that you do not have to pay out of your pocket for the appointment or treatment.

Visits to a specialist or allied healthcare provider (such as a physiotherapist or speech therapist) need to be referred by your Network GP, who will obtain authorisation from the GEMS Call Centre.

Pathology and radiology tests (blood tests and x-rays) must be in line with the GEMS formulary (list of approved tests or services) for Sapphire and Beryl and also require referral from your Network GP.

GEMS Medical Aid will be introducing a pathology and radiology claims validation service to assist in ensuring that these claims are managed appropriately when you claim.

Gems Medical Aid Ruby Option

The Ruby option includes a personal medical savings account (PMSA), hospital plan and a Block benefit. The PMSA pays for your out-of-hospital or day-to-day medical expenses. Once the PMSA limit is reached, the out-of-hospital claims will then be paid from the limited Block benefit.

There is a specific Ruby, Emerald and Onyx (REO) Network which is made up of general practitioners (GPs) who have agreed to charge the Scheme rate and follow the managed care rules applicable to the GEMS Network relevant for these options.

You do not have to use a REO Network GP, but if you do, you will not have to pay any out-of-pocket expenses for your consultations.

If you need to go to hospital, it is important to remember that GEMS medical aid members need pre-authorisation for all hospital visits, out-patient visits to a hospital, MRI scans, CT scans or radio-isotope studies, in-hospital physiotherapy, ambulance transportation and specialised dentistry.

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