Working towards a healthier you
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
2018 Dental Provider Guide 3
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:
2018 Dental Provider Guide4
CODE CODE DESCRIPTION LIMITATIONSCOVERED:
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):
2018 Dental Provider Guide 5
CODE CODE DESCRIPTION LIMITATIONSCOVERED:
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
fittinganewdentureYes Yes
8273 Impressiontorepair/additionCannotbecompletedwithin6monthsof
fittinganewdentureYes Yes
*Please notethatMaxillo-facialsurgeryissubjecttoanannualsub-limitofR20823perfamilyontheSapphireandBeryloptions
Table of benefits: Sapphire and Beryl (continued):
2018 Dental Provider Guide6
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
andorthognathicsurgery >Excludesorthodontictreatmentonpatientsolderthantheageof
21• Generalanaesthesiaandconscioussedation: >Subject topre-authorisationandmanagedcareprotocolsand
processes >Onlyapplicabletobeneficiariesundertheageof6,severetrauma
andimpactedthirdmolars >Impactedthirdmolars:200%ofSchemeratepayableforremoval
underconscioussedationindoctor’srooms >Anaesthetistsarerequiredtoobtainaseparateauthorisationfor
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
2018 Dental Provider Guide 7
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
andorthognathicsurgery >Excludesorthodontictreatmentonpatientsolderthantheageof
21
• Generalanaesthesiaandconscioussedation: >Subject topre-authorisationandmanagedcareprotocolsand
processes >Onlyapplicabletobeneficiariesundertheageof6,severetrauma
andimpactedthirdmolars >Impactedthirdmolars:200%ofSchemeratepayableforremoval
underconscioussedationindoctor’srooms >Anaesthetistsarerequiredtoobtainaseparateauthorisationfor
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.
2018 Dental Provider Guide8
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:
2018 Dental Provider Guide 9
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):
2018 Dental Provider Guide10
• 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
2018 Dental Provider Guide 11
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
2018 Dental Provider Guide12
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
2018 Dental Provider Guide 13
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
2018 Dental Provider Guide14
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.
2018 Dental Provider Guide 15
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
2. ANAESTHETICS
2.2Local
anaesthetics
LidocaineHClLocalInj
1%4 IJ SOLN A Consumables
LidocaineHClLocalInj
2%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-
Meprobamate-Caff-Cod
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
2018 Dental Provider Guide16
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
4 OR SUSR AMax4fills/
annum
Amoxicillin&K
ClavulanateForSusp
400-57MG/5ML
4 OR SUSR AMax4fills/
annum
Amoxicillin&K
ClavulanateTab250-125
MG
4 OR TABS AMax4fills/
annum
Amoxicillin&K
ClavulanateTab500-125
MG
4 OR TABS AMax4fills/
annum
Amoxicillin&K
ClavulanateTab875-125
MG
4 OR TABS AMax2fills/
annum
Amoxicillin(Trihydrate)
ForSusp125MG/5ML4 OR SUSR A
Max4fills/
annum
Amoxicillin(Trihydrate)
ForSusp250MG/5ML4 OR SUSR A
Max4fills/
annum
Amoxicillin(Trihydrate)
Cap250MG4 OR CAPS A
Max4fills/
annum
Amoxicillin(Trihydrate)
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
CloxacillinSodiumCap
500MG4 OR CAPS A
Max4fills/
annum
2018 Dental Provider Guide 17
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
CefadroxilForSusp500
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
Inj1GM4 IJ SOLR A Consumables
CeftriaxoneSodiumFor
IVSoln2GM4 IJ SOLR A Consumables
CefuroximeAxetilFor
Susp125MG/5ML4 OR SUSR A
Max2fills/
annum
CefuroximeSodiumFor
Inj250MG4 IJ SOLR A Consumables
CefuroximeSodiumFor
Inj750MG4 IJ SOLR A Consumables
Cephalexin250MG 4 OR TABS AMax2fills/
annum
Cephalexin500MG 4 OR TABS AMax2fills/
annum
18.1.3 Others Nonelisted
2018 Dental Provider Guide18
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
ClarithromycinForSusp
250MG/5ML4 OR SUSR A
Max2fills/
annum
ClarithromycinTab250
MG4 OR TABS A
Max2fills/
annum
ClarithromycinTab500
MG4 OR TABS A
Max2fills/
annum
ClarithromycinTabSR
24HR500MG4 OR TB24 A
Max2fills/
annum
ErythromycinEstolate
Cap250MG4 OR CAPS A
Max4fills/
annum
ErythromycinEstolate
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
4 OR TABS AMax4fills/
annum
2018 Dental Provider Guide 19
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
Sulfamethoxazole-
TrimethoprimTab800-
160MG
4 OR TABS AMax4fills/
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
GriseofulvinMicrosize
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.
2018 Dental Provider Guide20
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
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
2018 Dental Provider Guide 21
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
LidocaineHClLocalInj
1%4 IJ SOLN A Consumables
LidocaineHClLocalInj
2%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
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
2018 Dental Provider Guide22
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
KetorolacTromethamine
Inj30MG/ML4 IJ SOLN A Consumables
KetorolacTromethamine
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
2 OR TABS AMaxRx/7days
&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
1 OR SYRP AMax100ml/Rx
&3Rx/annum
Acetaminophenw/
CodeineSyrup150-4
MG/5ML
1 OR SYRP AMax100ml/Rx
&3Rx/annum
Acetaminophenw/
CodeineTab500-10MG1 OR TABS A
MaxRx/7days
&3Rx/annum
Acetaminophenw/
CodeineTab500-20MG2 OR TABS A
MaxRx/7days
&3Rx/annum
2018 Dental Provider Guide 23
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
Acetaminophenw/
CodeineTab500-8MG2 OR TABS A
MaxRx/7days
&3Rx/annum
Acetaminophen-
Diphenhydramine-Caff-
CodTab400-5-50-10
MG
2 OR TABS AMaxRx/7days
&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
2 OR CAPS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Doxylamine-Caffeine-
CodeineTab450-5-45-
10MG
2 OR TABS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Doxylamine-Caffeine-
CodeineTab450-5-50-
10MG
2 OR TABS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Meprobamate-Caff-Cod
Cap200-150-30-10MG
5 OR CAPS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Meprobamate-Caff-Cod
Cap320-150-48-8MG
5 OR CAPS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Meprobamate-Caff-Cod
Tab200-150-30-10MG
5 OR TABS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Meprobamate-Caff-Cod
Tab320-150-32-8MG
5 OR TABS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Meprobamate-Codeine
Cap400-200-8MG
5 OR CAPS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Meprobamate-Codeine
Tab500-125-10MG
5 OR TABS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Phenyltoloxamine-Caff-
CodTab400-12-32-8
MG
2 OR TABS AMaxRx/7days
&3Rx/annum
Acetaminophen-
Promethazinew/
CodeineSyrup120-6.5-5
MG/5ML
2 OR SYRP AMax200ml/Rx
&3Rx/annum
2018 Dental Provider Guide24
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
2 OR TABS AMaxRx/7days
&3Rx/annum
APAP-NaSalicylate-
Aloin-BuchuTab97.19-
48.59-0.65-32.4MG
0 OR TABS AMaxRx/7days
&3Rx/annum
ASA-APAP-
Meprobamate-Caff-Cod
Tab200-200-150-30-10
MG
5 OR TABS AMaxRx/7days
&3Rx/annum
Aspirinw/Codeine
DispersibleTab500-8
MG
2 OR TBDP AMaxRx/7days
&3Rx/annum
Aspirin-Acetaminophen
w/CodeineTab250-
250-10MG
2 OR TABS AMaxRx/7days
&3Rx/annum
Aspirin-Acetaminophen-
CaffeinePowdPack
453.6-324-64.8MG
0 OR POWD AMaxRx/7days
&3Rx/annum
Aspirin-Acetaminophen-
CaffeineTab226-160-32
MG
0 OR TABS AMaxRx/7days
&3Rx/annum
Aspirin-Acetaminophen-
CaffeineTab250-250-65
MG
0 OR TABS AMaxRx/7days
&3Rx/annum
Aspirin-Acetaminophen-
CaffeineTab400-100-30
MG
0 OR TABS AMaxRx/7days
&3Rx/annum
Aspirin-CaffeineTab325-
22MG0 OR TABS A
MaxRx/7days
&3Rx/annum
Aspirin-CaffeineTab400-
22.7MG0 OR TABS A
MaxRx/7days
&3Rx/annum
Aspirin-CaffeineTab400-
24MG0 OR TABS A
MaxRx/7days
&3Rx/annum
Aspirin-CaffeineTab500-
32MG0 OR TABS A
MaxRx/7days
&3Rx/annum
Ibuprofen-
AcetaminophenCap
200-250MG
2 OR CAPS AMaxRx/7days
&3Rx/annum
Ibuprofen-
AcetaminophenSusp
100-125MG/5ML
2 OR SUSP AMax100ml/Rx
&3Rx/annum
2018 Dental Provider Guide 25
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
Ibuprofen-
AcetaminophenTab
200-350MG
2 OR TABS AMaxRx/7days
&3Rx/annum
Ibuprofen-
AcetaminophenTab
400-325MG
3 OR TABS AMaxRx/7days
&3Rx/annum
Ibuprofen-
Acetaminophen-Codeine
Cap200-250-10MG
3 OR CAPS AMaxRx/7days
&3Rx/annum
Ibuprofen-
Acetaminophen-Codeine
Susp200-250-10
MG/10ML
3 OR SUSP AMax100ml/Rx
&3Rx/annum
Ibuprofen-
Acetaminophen-Codeine
Tab200-350-10MG
3 OR TABS AMaxRx/7days
&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
2 OR TABS AMaxRx/7days
&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
2018 Dental Provider Guide26
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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)
3 IV SOLN A Consumables
IbuprofenTab200MG 3 OR TABS AMaxRx/5days
&2Rx/annum
IbuprofenTab400MG 3 OR TABS AMaxRx/5days
&2Rx/annum
IbuprofenTab600MG 3 OR TABS AMaxRx/5days
&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
2018 Dental Provider Guide 27
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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-
ChlorhexidineGluconate
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
2018 Dental Provider Guide28
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
Benzydamine-
CetylpyridniumLozg
3-1.33MG
1 MT LOZG AMax24/Rx&4
Rx/annum
Benzydamine-
ChlorhexidineGluconate
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
1 MT LOZG AMax20/Rx&4
Rx/annum
Cetylpyridinium-
BenzocaineLozenge
2-10MG
1 MT LOZG AMax20/Rx&4
Rx/annum
ChlorhexidineGluconate
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
0 MT LOZG AMax20/Rx&4
Rx/annum
18. ANTI-MICROBIALS
18.1. Beta-lactams
18.1.1 Penicillins
Amoxicillin&K
ClavulanateForIVSoln
1000-200MG
4 IV SOLR A Consumables
2018 Dental Provider Guide 29
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
Amoxicillin&K
ClavulanateForIVSoln
500-100MG
4 IV SOLR A Consumables
Amoxicillin&K
ClavulanateForSusp
125-31.25MG/5ML
4 OR SUSR AMax4fills/
annum
Amoxicillin&K
ClavulanateForSusp
200-28.5MG/5ML
4 OR SUSR AMax4fills/
annum
Amoxicillin&K
ClavulanateForSusp
250-62.5MG/5ML
4 OR SUSR AMax4fills/
annum
Amoxicillin&K
ClavulanateForSusp
400-57MG/5ML
4 OR SUSR AMax4fills/
annum
Amoxicillin&K
ClavulanateForSusp
600-42.9MG/5ML
4 OR SUSR AMax4fills/
annum
Amoxicillin&K
ClavulanateTab250-125
MG
4 OR TABS AMax4fills/
annum
Amoxicillin&K
ClavulanateTab500-125
MG
4 OR TABS AMax4fills/
annum
Amoxicillin&K
ClavulanateTab875-125
MG
4 OR TABS AMax2fills/
annum
Amoxicillin&K
ClavulanateTabSR
12HR1000-62.5MG
4 OR TB12 AMax4fills/
annum
Amoxicillin(Trihydrate)
Cap250MG4 OR CAPS A
Max4fills/
annum
Amoxicillin(Trihydrate)
Cap500MG4 OR CAPS A
Max4fills/
annum
Amoxicillin(Trihydrate)
ForSusp100MG/ML4 OR SUSR A
Max4fills/
annum
Amoxicillin(Trihydrate)
ForSusp125MG/5ML4 OR SUSR A
Max4fills/
annum
Amoxicillin(Trihydrate)
ForSusp250MG/5ML4 OR SUSR A
Max4fills/
annum
Amoxicillin-FloxacillinCap
250-250MG4 OR CAPS A
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
2018 Dental Provider Guide30
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
AmpicillinSodiumForInj
250MG4 IJ SOLR A Consumables
AmpicillinSodiumForInj
500MG4 IJ SOLR A Consumables
Ampicillin-CloxacillinCap
250-250MG4 OR CAPS A
Max4fills/
annum
Ampicillin-CloxacillinFor
Inj125-125MG4 IJ SOLR A Consumables
Ampicillin-CloxacillinFor
Inj250-250MG4 IJ SOLR A Consumables
Ampicillin-CloxacillinFor
Inj500-500MG4 IJ SOLR A Consumables
Ampicillin-CloxacillinFor
Susp125-125MG/5ML4 OR SUSR A
Max4fills/
annum
CloxacillinSodiumCap
250MG4 OR CAPS A
Max4fills/
annum
CloxacillinSodiumCap
500MG4 OR CAPS A
Max4fills/
annum
CloxacillinSodiumForInj
250MG4 IJ SOLR A Consumables
CloxacillinSodiumForInj
500MG4 IJ SOLR A Consumables
FloxacillinSodiumCap
250MG4 OR CAPS A
Max4fills/
annum
PenicillinGBenzathine
ForIntramuscularSusp
1200000Unit
4 IM SUSR A Consumables
PenicillinGBenzathine
ForIntramuscularSusp
2400000Unit
4 IM SUSR A Consumables
PenicillinGProcaine
IntramuscularSusp
300000Unit/ML
4 IM SUSR A Consumables
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
4 IV SOLR A Consumables
18.1.2Cephalospor-
ins
CefaclorForSusp187
MG/5ML4 OR SUSR A
Max2fills/
annum
CefaclorForSusp375
MG/5ML4 OR SUSR A
Max2fills/
annum
2018 Dental Provider Guide 31
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
CefadroxilForSusp250
MG/5ML4 OR SUSR A
Max2fills/
annum
CefadroxilForSusp500
MG/5ML4 OR SUSR A
Max2fills/
annum
CefazolinSodiumForInj
1GM4 IJ SOLR A Consumables
CefazolinSodiumForInj
500MG4 IJ SOLR A Consumables
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
Inj1GM4 IJ SOLR A Consumables
CefotaximeSodiumFor
Inj500MG4 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
CefpodoximeProxetilTab
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
2018 Dental Provider Guide32
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
CeftriaxoneSodiumFor
Inj1GM4 IJ SOLR A Consumables
CeftriaxoneSodiumFor
Inj2GM4 IJ SOLR A Consumables
CeftriaxoneSodiumFor
Inj250MG4 IJ SOLR A Consumables
CeftriaxoneSodiumFor
Inj500MG4 IJ SOLR A Consumables
CeftriaxoneSodiumFor
IVSoln2GM4 IJ SOLR A Consumables
CefuroximeAxetilFor
Susp125MG/5ML4 OR SUSR A
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
Inj250MG4 IJ SOLR A Consumables
CefuroximeSodiumFor
Inj750MG4 IJ SOLR A Consumables
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
MG4 IJ SOLR A Consumables
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
2018 Dental Provider Guide 33
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
AzithromycinExtended
ReleaseForOralSusp
2GM
4 OR GRAN AMax2fills/
annum
AzithromycinForSusp
200MG/5ML4 OR SUSR A
Max2fills/
annum
AzithromycinIVForSoln
500MG4 IV SOLR A Consumables
AzithromycinTab500
MG4 OR TABS A
Max2fills/
annum
ClarithromycinForIV
Soln500MG4 IV SOLR A Consumables
ClarithromycinForSusp
125MG/5ML4 OR SUSR A
Max2fills/
annum
ClarithromycinForSusp
250MG/5ML4 OR SUSR A
Max2fills/
annum
ClarithromycinTab250
MG4 OR TABS A
Max2fills/
annum
ClarithromycinTab500
MG4 OR TABS A
Max2fills/
annum
ClarithromycinTabSR
24HR500MG4 OR TB24 A
Max2fills/
annum
ErythromycinEstolate
Cap250MG4 OR CAPS A
Max4fills/
annum
ErythromycinEstolate
Susp125MG/5ML4 OR SUSP A
Max4fills/
annum
ErythromycinEstolate
Susp250MG/5ML4 OR SUSP A
Max4fills/
annum
Erythromycin
LactobionateForInj1000
MG
4 IV SOLR A Consumables
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
GentamicinSulfateInj10
MG/ML4 IJ SOLN A Consumables
GentamicinSulfateInj40
MG/ML4 IJ SOLN A Consumables
18.4. Tetracyclines
18.4 TetracyclinesDoxycyclineHyclateCap
100MG4 OR CAPS A
Max4fills/
annum
2018 Dental Provider Guide34
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
DoxycyclineHyclateCap
50MG4 OR CAPS A
Max4fills/
annum
DoxycyclineHyclateCap
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
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
4 OR TABS AMax4fills/
annum
Sulfamethoxazole-
TrimethoprimTab800-
160MG
4 OR TABS AMax4fills/
annum
18.7 Quinolones
18.7 Quinolones
CiprofloxacinForOral
Susp250MG/5ML(5%)
(5GM/100ML)
4 OR SUSP AMax4fills/
annum
2018 Dental Provider Guide 35
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
CiprofloxacinHClTab
250MG(BaseEquiv)4 OR TABS A
Max4fills/
annum
CiprofloxacinHClTab
500MG(BaseEquiv)4 OR TABS A
Max4fills/
annum
CiprofloxacinHClTab
750MG(BaseEquiv)4 OR TABS A
Max4fills/
annum
CiprofloxacinLactateIV
Soln2MG/ML4 IV SOLN A Consumables
Ciprofloxacin-
CiprofloxacinHClTabSR
24HR1000MG(BaseEq)
4 OR TB24 AMax4fills/
annum
Ciprofloxacin-
CiprofloxacinHClTabSR
24HR500MG(BaseEq)
4 OR TB24 AMax4fills/
annum
GemifloxacinMesylate
Tab320MG(BaseEquiv)4 OR TABS A
Max4fills/
annum
LevofloxacinIVSoln5
MG/ML4 IV SOLN A Consumables
LevofloxacinTab250MG 4 OR TABS AMax4fills/
annum
LevofloxacinTab500MG 4 OR TABS AMax4fills/
annum
LevofloxacinTab750MG 4 OR TABS AMax4fills/
annum
MoxifloxacinHCl400
MG/250MLinSodium
Chloride0.8%Inj
4 IV SOLN A Consumables
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
175MG/5ML4 OR SUSP A
Max2fills/
annum
2018 Dental Provider Guide36
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
MG4 IJ SOLR A Consumables
TeicoplaninForInj400
MG4 IJ SOLR A Consumables
TigecyclineForIVSoln
50MG4 IV SOLR A Consumables
VancomycinHClForInj
1000MG4 IV SOLR A Consumables
VancomycinHClForInj
500MG4 IV SOLR A Consumables
18.10. Anti-fungal agents
18.10Anti-fungal
agents
AmphotericinBForInj
50MG4 IV SOLR A Consumables
AmphotericinB
LiposomeIVForSusp
50MG
4 IV SOLR A Consumables
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
GriseofulvinMicrosize
Tab125MG4 OR TABS A
Max2fills/
annum
GriseofulvinMicrosize
Tab500MG4 OR TABS A
Max2fills/
annum
2018 Dental Provider Guide 37
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
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
2018 Dental Provider Guide38
MIMSMIMS
DESCRIPTIONACTIVE INGREDIENT SCHEDULE
ROUTE
OF
ADMIN
DOSAGE
FORMACUTE
QUANTITIES
AND
LIMITATIONS
Betamethasone-
DexchlorpheniramineTab
0.25-2MG
4 OR TABS AMax3fills/
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
4 IV SOLR A Consumables
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
PrednisoneTab5MG 4 OR TABS AMax3fills/
annum
PrednisoneTab50MG 4 OR TABS AMax3fills/
annum
DisclaimerPleasenotethattheformularywillbereviewedregularlybyclinicalandpharmaceuticaladvisorstoensureitcomplieswiththelatestindustrynormsforthetreatmentoftheseconditions.GEMSreservestherighttochangemedicineontheformularywhenimportantinformationcomestolightthatrequiresustodosoe.g.newfindingregardingthesafetyofadrug.
2018 Dental Provider Guide 39
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
• 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
2018 Dental Provider Guide40
• Pleaseensureavailablebenefitcodesandtariffvalueisverifiedwith
theSchemewhereunsure.
• Thedentalprovider is required to verifymembershipdetailsand
confirmtheidentityofthepatient.
• TheSchemewillnotberesponsible foranypaymentofservices
excludedinaccordancewithSchemeormanagedcarerules.
• Memberswillbeheldfullyliableforanyclaimsincurredonbenefits
fallingoutsidethebenefitschedule.
• Benefitconfirmationviapre-authorisationisrequiredwhereindicated.
EightMember verification and validation
2018 Dental Provider Guide 41
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
2018 Dental Provider Guide42
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
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
Dental practitioner/therapist/specialist
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
2018 Dental Provider Guide 43
Example: Dental report for periodontal pre-authorisation(TheformsareavailableontheGEMSwebsiteatwww.gems.gov.za.Emailthecompletedformtoenquiries@gems.gov.zaorfaxto0861004367.)
Dental report forperiodontal pre-authorisation
Dental practitioner/therapist/specialist
Network provider code Practice no
Tel no (W) ( ) Fax no ( ) Cell phone no
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
2018 Dental Provider Guide44
Example: Patient consent form(TheformsareavailableontheGEMSwebsiteatwww.gems.gov.za.Emailthecompletedformtoenquiries@gems.gov.zaorfaxto0861004367.)
2018 Dental Provider Guide 45
Working towards a healthier you
CONTACT GEMS
Call0860004367
Fax 0861004367
Address
PrivateBagx782,CapeTown,8000
www.gems.gov.za