Dental Guide - The Competition Commission of South … is your copy of the 2016 GEMS Dental Provider ... dental benefit spectrum and budgetary parameters ... Your 2016 Dental Guide

Your 2016

Dental Guide

working towards a healthier you

Table of Contents

01 Introduction 0302 Sapphire and Beryl, General Administration, Benefits and

Procedures covered 0503 Ruby, Emerald and Onyx: General Administration, Benefits

and Procedures covered 1204 General exclusions and restrictions excludes PMB

(Prescribed Minimum Benefits) 1805 Medicine 2106 Pre-authorisation 3807 Claim Procedures 3908 Member verification and validation 4009 Radiology Codes 4110 Exclusions 4211 Ex-Gratia 4312 Forms 44

01 IntroductionDear Dental Service Provider

This is your copy of the 2016 GEMS Dental Provider manual to assist and guide you regarding the dentistry benefits and Scheme managed care rules for 2016. Time and age rules, general principles and exclusions are all set out in the manual. How this is applied to the different dental procedures and the specific application to the different options are also stipulated. We recommend that you take time to familiarise yourself with the content to ensure optimal delivery of dental services to GEMS beneficiaries as well as to prevent any unnecessary frustration within your practice.

It is a priority within GEMS to ensure equitable access to affordable and comprehensive healthcare benefits to all our members. We rely on you, as a valued Dental Service Provider, to ensure our members’ expectations are realised.

It takes a team effort between the Scheme and Healthcare Providers to ensure high quality clinical and administrative services to our members. We therefore extend an invitation to you to become an integral part of this team by becoming a GEMS Service Provider Network member and Friend of GEMS. For details and immediate assistance on how to join the growing GEMS Dental Service Provider Network, kindly contact us on 0860 436 777.

Please be assured that we recognise and appreciate your importance as a vital link in the dental service value chain to ensure that GEMS beneficiaries receive only the highest quality of dental care.

GEMS remains committed to ensuring appropriate care to its beneficiaries. In this regard, should you have any comments or suggestions you wish us to consider, please e-mail us at [email protected].

Dental Managed Care Programme:

The Dental Managed Care Programme applies to all GEMS options namely Sapphire, Beryl, Ruby, Emerald and Onyx. The motivation around Dental Managed Care is not to impinge on the practitioner’s diagnosis in any way, It is to ensure rational, appropriate and cost effective treatment to all GEMS beneficiaries within the dental benefit spectrum and budgetary parameters applying within such patient’s scheme option, in accordance with accepted dental treatment guidelines and protocols.

Call centre enquiries and interaction could be minimized by ensuring that you are well-acquainted with procedure schedules, exclusions, age-and-time rules and specific treatment conditions necessitating pre-authorisation that apply to the different options as outlined in detail within this Service Provider Manual.

Benefits

Note: Should you have any queries regarding

Rules

Exclusions

Pre-authorisation

etc.

As they apply to your patient on their specific scheme option, please contact the Scheme call centre on 0860 436 777.

3Your 2016 Dental Guide

Pre-authorisation, Pre-notification and Patient Registration

Please refer to the “Dental Report for Patient registration, Pre-notification and Pre-authorisation” Form (included in this manual) to be completed and forwarded to the Scheme in the event of:• Patient registration: During the patient’s first visit to

your practice a once-off dental charting and oral examination in association with code 8101 (as per normal prescribed guidelines associated with the charging of code 8101) needs to be performed and the form then submitted to GEMS. This allows for the centralised capturing of the patient’s existing oral status to ensure proper and appropriate dental managed care and risk management in accordance with internationally recognised standards. It also allows us to compile an actual and dynamic epidemiologic database of the GEMS patient population for future benefit and budgetary planning.

• Pre-authorisation and/or a treatment plan: This is required for certain dental procedures as indicated in the procedure schedules within this manual pertaining to each specific option.

They include, but are not limited to, certain specialised and surgical procedures, orthodontics, periodontal treatment and all procedures planned to be performed in an operating theatre or under Conscious Sedation. Important: Where pre-authorisation and/or treatment plans are required the standard “Patient Registration, Pre-notification and Pre-authorisation” form should be completed

Note: It is only necessary to complete the applicable sections, for instance, it is not necessary to complete the charting section with each authorisation request. The completed form should be submitted to [email protected] or faxed to 0861 00 4367.

We look forward to being of service to you and your patients.

Once again, do not hesitate to contact for any queries on 0860 436 777.

02 Sapphire and BerylGeneral 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 9)

• Services must be provided by a GEMS dental network service provider only.

• Examinations and preventative treatment: Two consultation/ examination and preventative treatment episodes per beneficiary per benefit year.

• Restorative treatment – 2 events per beneficiary per year - limited to a total of four restorations per beneficiary per year.

• Posterior resins paid at the same rand value as amalgam fillings.

• Pain and sepsis – limited to two events/annum – refer table (page 7) for procedures covered.

• One emergency visit per beneficiary per year.

• Dentures limited to the approved 2016 Scheme tariff.

• All dentures subject to pre-authorisation.

• No specialised dentistry benefit - limited to PMB’s.

• All services are subject to an approved list of tariff codes, managed care protocols and processes.

• Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice for the first time to be submitted to the Scheme on the “Dental Report for Registration, Pre-notification and Pre-authorisation” Form.

Summarised benefits offered by Beryl: (For a detailed benefit matrix refer to page 8)

• Services must be provided by a dental network service provider only.

• Examinations and Preventative treatment: Two consultation/examination and preventative treatment episodes per beneficiary per benefit year.

• Restorative treatment – 2 events per beneficiary per year – limited to a total of four restorations per beneficiary per year (pre-authorisation needed for more than 4 fillings).

• Pain and sepsis – limited to two events/annum – refer table (page 7) for procedures covered

• One emergency visit per beneficiary per year.

• Dentures and Specialised dentistry services limited to R3 074 per beneficiary per annum.

• All dentures and specialised dentistry subject to pre-authorisation.

• All services are subject to an approved list of tariff codes, managed care protocols and processes.

• Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice for the first time to be submitted to the Scheme on the “Dental Report for Registration, Pre-notification and Pre-authorisation” Form.


Sapphire and Beryl Options – Specific rules that apply

Essential Dentistry:

• Approved list of services/codes are covered at 100% of the agreed tariff subject to the availability of funds.

• Pain and sepsis treatment:

> Maximum two events per beneficiary per benefit year.

> Codes covered – 8132, 8201 and code 8307 (code 8307 only applies on primary teeth).

> Extractions:

– Normal/routine extraction: One event per year. If the extraction is indicated due to pain and sepsis, another event will apply.

– Only covered if clinically indicated.

• General anaesthetics and conscious sedation:

> Subject to the rules of the Scheme, relevant managed care protocols and pre-authorisation.

Emergency Dentistry

• Approved dental codes are 8132; 8201 and 8307 (as per pain and sepsis treatment).

• Emergency pain and sepsis treatment only.

• Pulpotomy on primary teeth only.

• Any additional treatment requires funding by patient.

• One event per beneficiary per benefit year allowed for emergency dentistry.

Dentures

For the Sapphire and Beryl option:• 1 (one) set of plastic dentures allowed per beneficiary

per 48 month benefit cycle.

• A set of dentures is defined as follows: − Complete upper and lower dentures.

> Complete upper or lower dentures (not 2 upper or 2 lower). − Partial upper and lower dentures.

> Partial upper or lower denture (not 2 partial upper or 2 partial lower).

• Only members and beneficiaries over the age of 21 years qualify for this benefit.

• Pre-authorisation via the GEMS network call centre required.

The following table summarises the reimbursement codes relating to dentures:

• When claiming via Electronic Data Interchange (EDI), use individual nine codes for dental laboratories. Lab invoices to be retained by the practice for possible auditing purposes.

• When submitting paper claims use individual nine codes for dental laboratories and submit the dental laboratory invoice together with the paper invoice.

• No claim will be accepted without the professional fee and laboratory codes submitted together or being matched in the event of a lab performing self-billing.

Please Note:• No benefit for metal base to partial

or complete dentures for the Sapphire option

• No cover where teeth are lost as a result of negligence

• A motivation is required for the replacement of dentures lost due to traumatic injury, for example lost in MVA at accident scene due to paramedic resuscitations. Please direct all motivations to the network call centre on 0860 436 777.

Codes Not Funded Codes Funded

8658 (interim complete denture) 8231 to 8241

8659 (interim partial denture) 8269

8661 (diagnostic dentures) 8271

8244 (immediate upper denture) 8273

8245 (immediate lower denture) 8259

8281, 8663, 8279 (metal base codes) 8263

Individual Laboratory Codes

6 Your 2016 Dental Guide

Code Code Description Limitations

Limitations Covered: Sapphire

Covered: Beryl

8101 Consultation Two per beneficiary per year Yes Yes

8104 Examination for a specific problem not requiring full mouth examination

Two per beneficiary per year Yes Yes

8107/ 8112

Intra oral radiographs, per film

Maximum of two per beneficiary per year

Yes. One event per year applies

Yes. One event per year applies

8155 Polishing – complete dentition

Two per beneficiary per 12 months. Cannot be charged with 8159 in same year

Yes Yes

8159 Scaling and polishing Two per beneficiary per 12 months; only over the age of 12 years.

Yes Yes

8161 Topical application of fluoride

Between the ages of 3-12 years. Once per beneficiary per 12 months.

Yes Yes

8163 Fissure sealant, per tooth

Patient younger than 14; maximum of 2 per quadrant on posterior permanent teeth only

Yes Yes

8341 Amalgam one surface Any four amalgam fillings per beneficiary per year. Subject to an overall limit of four restorations per beneficiary per year.

Yes – Two events/ annum applies


8342 Amalgam two surfaces

8343 Amalgam three surfaces

8344 Amalgam four and more surfaces




Covered: Beryl

8351 Resin restoration, one surface anterior

Any four resin fillings per beneficiary per year (anterior). Subject to an overall limit of four restorations per beneficiary per year.



8354 Resin restoration, four and more surfaces

8367 Resin restoration, one surface posterior

Any four resin fillings per beneficiary per year (posterior). Subject to an overall limit of four restorations per beneficiary per year.

Yes, but to the same Rand value as same surfaces amalgam filling and two events/ annum applies.

Yes – Two events/ annum applies.

8368 Resin restoration, two surface posterior

8369 Resin restoration, three surface posterior

8370 Resin restoration, four and more surface

8307 Amputation of pulp (pulpotomy)

Only on primary teeth Yes two events/ annum

Yes – two events/ annum

8132 Root canal therapy – gross pulpal debridement

Yes – one event/ annum applies

Yes – one event per annum applies

8201 Extraction, single tooth. Code 8201 is charged for the first extraction in a quadrant.

Any four non-surgical extractions per beneficiary per year – ONLY if clinically indicated.

Yes – one event per annum applies. Two events if necessitated by pain and sepsis


8202 Extraction, each additional tooth. Code 8202 is charged for each additional extraction in the same quadrant.

Any four non-surgical extractions per beneficiary per year apply (in association with code 8201)



8937 Surgical removal of tooth*

Quantity limit of two. Pre-authorisation necessary for more than two

Yes – one event per annum applies. Benefit from 12 years

Yes – one event per annum applies. Benefit from 12 years




Covered: Beryl

8213 Surgical removal of residual roots, first tooth - per tooth*

Maximum of 1 procedure applies. More than 1 requires clinical motivation.

Yes - One event per year applies. Benefit from 12 years


8214 Surgical removal of residual roots, second and subsequent teeth’s roots*

Maximum of 1 procedure applies. More than 1 requires clinical motivation.



8941 Surgical removal of impacted tooth – first tooth*

Pre-auth required for in-hospital Yes Yes

8943 Surgical removal of impacted tooth – second tooth*


8945 Surgical removal of impacted tooth – third and subsequent teeth*


8220 Sutures In association with surgical extractions and/or impactions. Quantity limited to once per year

Yes Yes

8935 Treatment of septic socket

Yes – one event per year applies

Yes – one event per year applies

8109 Infection control/barrier techniques. Code 8109 includes the provision by the dentist of new rubber gloves, masks etc. for each patient

Two per visit Yes Yes

8110 Sterilised instrumentation

One per visit Yes Yes

8145 Local anaesthetic One per visit Yes Yes




Covered: Beryl

8231 Complete dentures – maxillary and mandibular

• 1 (one) set of dentures allowed per beneficiary per 48 months.

• Pre-authorisation necessary ONLY members and beneficiaries over the age of 21 years of age.

• ONLY plastic dentures for the Beryl and Sapphire options.

Yes Yes

8232 Complete dentures – maxillary or mandibular

Yes Yes

8233 Partial Denture (resin base) – One tooth

Yes Yes

8234 Partial Denture (resin base) – Two teeth

Yes Yes

8235 Partial Denture (resin base) -Three teeth

Yes Yes

8236 Partial Denture (resin base) – Four teeth

Yes Yes

8237 Partial Denture (resin base) – Five teeth

Yes Yes

8238 Partial Denture (resin base) – Six teeth

Yes Yes

8239 Partial Denture (resin base) Seven teeth

Yes Yes

8240 Partial Denture (resin base) -Eight teeth

Yes Yes

8241 Partial Denture (resin base) – Nine teeth and more

Yes Yes

8259 Rebase complete or partial dentures (lab)

Rebase only allowed once every two years

Yes Yes

8269 Repair Denture Cannot be completed with 6 months of fitting a new denture

Yes Yes

8263 Reline complete or partial dentures (chair side)

Reline only allowed once every two years

Yes Yes




Covered: Beryl

8271 Add tooth to existing partial dentures

Cannot be completed with 6 months of fitting a new denture

Yes Yes

8273 Impression to repair/addition

Cannot be completed with 6 months of fitting a new denture

Yes Yes

*Please note that Maxillo facial surgery is subject to a sub-limit of R18 638 on the Sapphire and Beryl options

03 Ruby, Emerald and Onyx:General Administration, Benefits and Procedures covered

Summarised benefits covered on Ruby, Emerald and Onyx

Summarised benefits covered on Ruby;

� Services not limited to dental network service providers

� Shared overall dental limit with in-hospital dentistry of R 2, 864 per beneficiary per annum

� Conservative and restorative dentistry (including plastic dentures):

> 100% of Scheme rate subject to available funds

� Specialised dentistry (including Maxillo-facial benefits):

> Pre-authorisation needed (except for metal based dentures)

> Excludes osseo-integrated implants, all implant related procedures and orthognathic surgery

> Excludes orthodontic treatment on patients older than 21 years

� General anaesthesia and conscious sedation:

> Subject to pre-authorisation and managed care protocols and processes

> General anaesthesia is subject to a one day, non-PMB limit of R15 034 per beneficiary per annum

> Only applicable to beneficiaries under the age of eight years, severe trauma and impacted third molars

> Impacted third molars: 200% of Scheme rate payable for removal under conscious sedation in doctor’s rooms

> Anaesthetists are required to obtain a separate authorisation for dental related conscious sedation procedures

� Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice for the first time to be submitted to the Scheme on the “Dental Report for Registration, Pre-notification and Pre-authorisation Form”

Summarised benefits covered on Emerald

> 100% of Scheme rate subject to available funds

� Specialised dentistry (including Maxillo-Facial benefits):



> Excludes orthodontic treatment on patients older than 21 years

> Subject to the stated overall dental limit of R 4,402 per beneficiary per annum which includes metal based dentures



> General anaesthesia is subject to a one day, non-PMB limit of R15 034 per beneficiary per annum

> Only applicable to beneficiaries under the age of eight years, severe trauma and impacted third molars


> Anaesthetists are required to obtain a separate authorisation for dental related conscious sedation procedures



� Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice for the first time to be submitted to the Scheme on the Dental Report - Registration, Pre-notification and Pre-authorisation Form.

Summarised benefits covered on Onyx:

� Services not limited to dental network service providers

� Shared overall dental limit with in-hospital dentistry of R 7 854 per beneficiary per annum

� Conservative and restorative dentistry (including plastic dentures):

> 100% of Scheme rate subject to available funds.

� Specialised dentistry (including Maxillo facial benefits):



> Excludes orthodontic treatment on patients older than 21 years.



> General anaesthesia is subject to a one day, non-PMB limit of R15 034 per beneficiary per annum Only applicable to beneficiaries under the age of eight years, severe trauma and impacted third molars

Conservative/basic dentistry,


> Anaesthetists are required to obtain a separate authorisation for dental related conscious

sedation procedures.

� Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice for the first time to be submitted to the Scheme on the “Dental Report for Registration, Pre-notification and Pre-authorisation Form”

� 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.


Ruby Emerald Onyx

Dental Consultation Annual Check-up

2 annual consultations per beneficiary, one every 6 months



Diagnostics 8107 - Diagnosis and treatment procedures where necessary

8107 - Diagnosis and treatment procedures where necessary

8107 - Diagnosis and treatment procedures where necessary

8108 – Benefit from 6 years and one every 24 months



8112 – Maximum of two per 12 months



8115 – Benefit from 6 years – max one every 24 months



8116, 8114 – Orthodontic treatment related – treatment plan and pre-authorisation applies



Infection Control

8109 – Infection control/barrier techniques: Twice per visit



8110 – Sterilised instrumentation: Once per visit



Ruby, Emerald & Onyx: General Rules

Ruby Emerald Onyx

Preventative Dentistry

Scale and polish 8159: Once every 6 months – from 12 years only



Polish 8155: Once every 6 months



Fluoride treatment – 8161 paid once every 6 months under age of 12



Fluoride treatment – 8162 paid once every 6 months from 12 years



Dental Sealant – max two per quadrant and once every two years per tooth – no benefit if tooth already in mouth for more than 4 years and for older than eighteen years



Restorations/ Fillings

Benefits available where clinically indicated – Fillings allowed once per tooth in a one year period

Benefits available where clinically indicated – Allowed once per tooth in a one year period

Benefits available where clinically indicated – Allowed once per tooth in a one year period

Dentures 1 set of full, or full upper or full lower, or partial upper and/or partial lower plastic dentures every 4 years. Relines,rebase, soft base every two years. Metal framework every 5 years.

1 set of full, or full upper or full lower, or partial upper and/or partial lower plastic dentures every 4 years. Relines,rebase, soft base every two years. Metal framework every 5 years.

1 set of full, or full upper or full lower, or partial upper and/or partial lower plastic dentures every 4 years. Relines, rebase, soft base every two years. Metal framework every 5 years.

Endodontic (Root canal) treatment

Pre-authorisation necessary for patients under the age of 14. Note: 8132 not allowed on same day as root treatment. A maximum of three treatment associated peri-apical x-rays allowed (thereafter pre-authorisation necessary)

Pre-authorisation necessary for patients under the age of 14. Note: 8132 not allowed on same day as root treatment. A maximum of three treatment associated peri-apical x-rays allowed (thereafter pre- authorisation necessary)

Pre-authorisation necessary for patients under the age of 14. Note: 8132 not allowed on same day as root treatment. A maximum of three treatment associated peri-apical x-rays allowed (thereafter pre- authorisation necessary)


Specialised Dentistry

Ruby Emerald Onyx

Crowns and bridges

Pre-authorisation necessary. Benefit once per tooth per 4 years

Pre-authorisation necessary. Benefit once per tooth per 4 years

Pre- authorisation necessary. Benefit once per tooth per 4 years

Orthodontics Treatment plan necessary – limited to patients under 21 years

Treatment plan necessary – limited to patients under 21 years

Treatment plan necessary – limited to patients under 21 years

Periodontics Treatment plan necessary Treatment plan necessary Treatment plan necessary

Maxillo facial & Oral/Dental Surgery

Pre-authorisation necessary when done in-theatre or under conscious sedation. Impacted wisdom teeth paid at 200% of rate when performed under conscious sedation in dentist’s rooms



Ruby Emerald Onyx

Dental Hospitalisation

Only allowed under the age of eight, bony impactions and severe trauma (PMB). Subject to pre-authorisation, treatment protocols and PMB conditions applying



Dental Hospitalisation



General principles applying

� All dental procedures are covered as per the rules applying per specific Scheme option

� All specialised dentistry and in-hospital dentistry are subject to pre-authorisation before commencement of treatment except in the event of an emergency where retrospective authorisation should be obtained within 72 working hours after the event

� An authorisation granted is not a guarantee of payment. Payment strictly remains subject to the availability of funds

� Confirmation of benefits is not a guarantee of payment – payment strictly remains subject to the availability of funds

� Hospital authorisations are valid for a period of one month and all other authorisations are valid for a period of three months.

� Where the dental treatment plan changes, the authorisations must be updated prior to submitting the claim.

Orthodontic treatment:

� Benefits only applicable on beneficiaries under the age of 21

� Authorisation and a treatment plan apply and benefits subject to prior evaluation according to the ICON criteria – Index of Complexity, Outcome and Treatment Need.

� Once approved an initial amount will be payable and the balance in increments subject to the availability of funds

� Approved treatment plans are valid for 1 year

� In the event that a case gets transferred to another provider only the balance due as per original treatment plan would be covered

� Orthodontic Exclusions: Refer to “General Exclusions and Restrictions”.

Hospitalisation

� Only covered for patients under the age of eight, bony third impactions and severe trauma as per Scheme rules.

� No other procedures apply

� Subject to pre-authorisation

� Children under eight:

> Only considered where no other options are available.

> All procedures necessary to be completed in one theatre-associated event.

> Only necessary restorative and surgical (e.g. extractions) procedures may be performed. No preventative treatment (polish, fluoride treatment, fissure sealants) will be covered in theatre.

04 General exclusions and restrictions excludes PMB (Prescribed Minimum Benefits)

Diagnostic/Preventative treatment

Fillings, Restorations

Dentures

• Special report

• Dental testimony

• Microbiological studies

• Caries susceptibility tests

• Diagnostic models only covered in association with orthodontic treatment

• Appointment not kept

• Nutritional counselling

• Tobacco counselling

• Oral hygiene instruction and/or associated visits

• Removal of gross calculus

• Behaviour management

• Cost of toothbrushes, toothpastes and mouthwashes

• Fissure sealants in patients older than 18 years or where teeth have been in the mouth for more than 4 years

• Oral and/or facial image (digital and conventional) – only covered where orthodontic treatment applies

• Resin bonding for restorations charged separately from the restoration

• Enamel micro abrasion

• Elective replacement of fillings

• Gold or gold foil restorations

• Diagnostic dentures

• Snoring apparatus

• Clasp or rest – cast gold

• Clasp or rest – wrought gold

• Inlay in denture

• Metal base to full dentures

• Metal frames for partial dentures limited to one per jaw and once every four years


Crown and bridge

Implants

Orthodontic treatment exclusions

• Where an underlying periodontal condition (e.g. extensive loss of alveolar bone) compromises an acceptable term prognosis

• Where a lack of remaining tooth structure compromises an acceptable prognosis

• Where enough remaining tooth structure does not justify a crown as the restoration of choice

• On a failed root canal treated tooth

• For cosmetic reasons

• Allowed once per tooth every four years

• Emergency crowns not placed for immediate protection of injured teeth

• Temporary and provisional crowns including lab costs

• Pontics on second molars

• On primary teeth or third molars

• Cost of gold, semi-precious metal and platinum foil

• 8570 – computer generated restoration: Lab not allowed with this code (only 8560)

• All implant related clinical and laboratory associated procedures (includes implant placement, cost of components, restorations/crowns/bridges/dentures/repairs associated with implants

• Re-treatment of orthodontic treatment

• Lost appliances not covered

• Lingual orthodontics not covered

• Ceramic brackets not covered

• Re-fixing of orthodontic brackets not covered

• Retainers limited to one per jaw

• Treatment planning for orthognathic surgery

Endodontic treatment

• On third molars

• On primary teeth

• Emergency root canal treatment charged on the same day as the completed root canal treatment

• Re-treatment not covered within 2 years of initial treatment

• Motivation required for treatment under the age of 14


Other

• Cosmetic dentistry

• The treatment of any complication related to treatment not funded by the Scheme.

• Intramuscular and subcutaneous injections

• All procedures related to bleaching (except internal bleaching on previously endodontically treated teeth)

• Perio chip replacement

• Treatment plan completed (code 8120)

• Cost of mineral trioxide

• Ozone therapy

• Cost of gold, semi-precious metal and platinum foil

• Orthognathic surgery and related hospital costs

• Occlusal adjustment minor (for major occlusal adjustment pre-auth necessary)

• Bone regeneration procedures

• Cost of bone regenerative/repair material

• Any lab costs where the associated procedure is not covered

• Inlays and onlays:

> Exclude tooth numbers 1 to 3 in all quadrants

> No benefit for gold or precious metal

> Allowed once every four years

• MRI or CAT scans for dental purposes not covered

In-Hospital (Theatre)

• Only covered for patients under the age of eight, bony third impactions and severe trauma as per Scheme rules. No other procedures apply

• Preventative dental procedures as part of the dental treatment performed on children under the age of eight not covered


05 Medicine• Medicine may be prescribed:

> According to the GEMS dental medicine formulary.

> By an approved GEMS network dentist or Dental Therapist (within their scope) in the event of the

• Sapphire or Beryl options:

> Medicine must be dispensed by approved GEMS network or courier pharmacies or Dispensing Dentists.

• Please refer to the respective formularies that apply to the Sapphire/Beryl and Ruby/Emerald/Onyx options below for detailed guidance.

GEMS Sapphire and Beryl Dental Medicine Formulary 2016

Please note: provider Trade Names are not listed on formulary, allowing for generic substitution, but applying Reference Pricing.

Key to quantities and limitations

1. “Consumables” means the medication may only be administrated by a DSP at the rooms. All injectables are consumables and claims for scripts given to patients to collect from DSP pharmacies will be rejected.

2. “Max Rx/7 days & 3 Rx/annum” means a script filled up to a maximum of 7 days medicine supply and 3 prescriptions per year can be claimed.

3. Benefits for medicine are subject to Reference Pricing (MPL) and exlusion lists (MEL). Should the cost of the item exceed MPL, the patient will be liable for payment of the difference in cost. If this is the case please inform the patient that it will be for his/her own personal account.

4. Dental therapists may prescribe as per the latest government gazette published by the Dept. of Health.


MIMS Mims Description

Active Ingredient Sdcheule Route of admin

Dosage Form

Acute Quantities and Limitations

2. Anaesthetics

2.2 Local Anaesthetics

Lidocaine HCl Local Inj 1% 4 IJ SOLN A ConsumablesLidocaine HCl Local Inj 2% 4 IJ SOLN A ConsumablesLidocaine Inj 2% w/ Epinephrine-1:80000 4 IJ SOLN A Consumables

3. Analgesics

3.2. Analgesics and antipyretics

3.2 Analgesics & antipyretics Ibuprofen Susp 100 MG/5ML 2 OR SUSP A Max 200ml/Rx & 3 Rx/

annum

Paracetamol Elixir 120 MG/5ML 0 OR ELIX A Max 200ml/Rx & 3 Rx/annum

Paracetamol Suppos 125 MG 2 RE SUPP A Max 1 op/Rx & 1 Rx/annum

Paracetamol Suppos 250 MG 2 RE SUPP A Max 1 op/Rx & 1 Rx/annum

Paracetamol Tab 500 MG 0 OR TABS A Max Rx/7 days & 3 Rx/annum

3.3. Combination Analgesics

3.3 Combination Analgesics Paracetamol w/ Codeine Tab 500-10 MG 1 OR TABS A Max Rx/7 days & 3 Rx/

annumParacetamol w/ Codeine Syrup 150-4 MG/5ML 1 OR SYRP A Max 100ml/Rx & 3 Rx/

annumAcetaminophen-Meprobamate-Caff-Cod 320-150-32-8 MG 5 OR TABS A Max Rx/7 days & 3 Rx/

annumAcetaminophen-Meprobamate-Caff-Cod 320-150-48-8 MG 5 OR CAPS A Max Rx/7 days & 3 Rx/

annumParacetamol-Promethazine w/ Codeine Syrup 120-6.5-5 MG/5ML 2 OR SYRP A Max 100ml/Rx & 3 Rx/

annum

4. Musculo-Skeletal Agents

4.1 Non-Steroidal Anti-Inflammatory Agents

4.1.1 COX Inhibitors Ibuprofen Tab 200 mg 3 OR TABS A Max Rx/7 days & 3 Rx/annum

Ibuprofen Tab 400 mg 3 OR TABS A Max Rx/7 days & 3 Rx/annum

11. Ear, Nose and Throat

11.3 Mouth and throat preparations

11.3

Mouth and throat preparations Benzocaine Lozenge 10 MG 1 MT LOZG A Max 20l/Rx & 4 Rx/

annumChlorhexidine Gluconate Soln 0.2% 0 MT SOLN A Max 200ml/annumPovidone-Iodine Mouthwash 1% 0 MT SOLN A Max 200ml/annumTetracaine HCl Ointment 0.5% 1 MT OINT A Max 1 op/annum


MIMS Mims Description

Active Ingredient Sdcheule Route of admin

Dosage Form

Acute Quantities and Limitations

18.2. Erythromycin and other macrolides

18.2 Erythromycin and other macrolides

Clarithromycin For Susp 125 MG/5ML 4 OR SUSR A Max 2 fills/annumClarithromycin For Susp 250 MG/5ML 4 OR SUSR A Max 2 fills/annumClarithromycin Tab 250 MG 4 OR TABS A Max 2 fills/annumClarithromycin Tab 500 MG 4 OR TABS A Max 2 fills/annumClarithromycin Tab SR 24HR 500 MG 4 OR TB24 A Max 2 fills/annumErythromycin Estolate Cap 250 MG 4 OR CAPS A Max 4 fills/annumErythromycin Estolate Susp 125 MG/5ML 4 OR SUSP A Max 4 fills/annumRoxithromycin Tab 150 MG 4 OR SUSP A Max 2 fills/annum

18.3. Aminoglycosides

18.3 Aminoglycosides Gentamicin Sulfate Inj 40 MG/ML 4 IJ SOLN A Consumables18.4. Tetracyclines

18.4 Tetracyclines Doxycycline Hyclate Cap DR Particles 50 MG 4 OR CPEP A Max 4 fills/annumDoxycycline Hyclate Cap 100 MG 4 OR CAPS A Max 4 fills/annumMinocycline HCl Cap 50 MG 4 OR CAPS A Max 4 fills/annumMinocycline HCl Cap 100 MG 4 OR CAPS A Max 4 fills/annumOxytetracycline HCl Cap 250 MG 4 OR CAPS A Max 4 fills/annum

18.5. Chloramphenicols

18.5 Chloramphenicols Chloramphenicol Cap 250 MG 4 OR CAPS A Max 4 fills/annumChloramphenicol Susp 125 MG/5ML 4 OR SUSP A Max 4 fills/annum

18.6. Sulphonamides and combinations

18.6 Sulphonamides and combinations

Sulfamethoxazole-Trimethoprim IV Soln 400-80 MG/5ML 4 IV SOLN A Consumables

Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML 4 OR SUSP A Max 4 fills/annum

Sulfamethoxazole-Trimethoprim Tab 400-80 MG 4 OR TABS A Max 4 fills/annum

Sulfamethoxazole-Trimethoprim Tab 800-160 MG 4 OR TABS A Max 4 fills/annum

18.7 Quinolones

18.7 Quinolones Ciprofloxacin HCl Tab 250 MG 4 OR TABS A Max 4 fills/annumCiprofloxacin HCl Tab 500 MG 4 OR TABS A Max 4 fills/annum

18.9. Other anti-bacterial agents

18.9 Other anti-bacterial agents Clindamycin HCl Cap 150 MG 4 OR CAPSA A Max 2 fills/annum

18.10. Anti-fungal agents

18.10 Anti-fungal agents Fluconazole Cap 150 MG 4 OR CAPS A Max 2 fills/annumGriseofulvin Microsize Tab 125 MG 4 OR TABS A Max 2 fills/annumGriseofulvin Microsize Tab 500 MG 4 OR TABS A Max 2 fills/annumNystatin Susp 100000 Unit/ML 4 MT SUSP A Max 2 fills/annum

18.11. Anti-protozoal agents

18.11 Anti-protozoal agents

Metronidazole Susp 200 MG/5ML 4 OR SUSP A Max 3 fills/annumMetronidazole Tab 200 MG 4 OR TABS A Max 3 fills/annumMetronidazole Tab 400 MG 4 OR TABS A Max 3 fills/annum

19. Endocrine System

19.5. Corticosteroids

19.5 Corticosteroids Prednisone Tab 5 MG 4 OR TABS A Max 3 fills/annum


Disclaimer

Please note that the formulary will be reviewed regularly by clinical and pharmaceutical advisors to ensure it complies with the latest industry norms for the treatment of these conditions. GEMS reserves the right to change medicine on the formulary when important information comes to light that requires us to do so e.g. new finding regarding the safety of a drug.

Key to quantities and limitations

1. “Consumables” means the medication may only be administrated by a DSP at the rooms. All injectables are consumables and claims for scripts given to patients to collect from DSP pharmacies will be rejected.

2. “Max Rx/7 days & 3 Rx/annum” means a script filled up to a maximum of 7 days medicine supply and 3 prescriptions per year can be claimed.

3. Benefits for medicine are subject to Reference Pricing (MPL) and exlusion lists (MEL). Should the cost of the item exceed MPL, the patient will be liable for payment of the difference in cost. If this is the case please inform the patient that it will be for his/her own personal account.

4. Dental therapists may prescribe as per the latest government gazette published by the Dept. of Health.

B: Dental Medicine Formulary – GEMS Ruby, Emerald and Onyx Options:GEMS RUBY, EMERALD AND ONYX (REO) Dental Medicine Formulary 2016

Please note: Provider Trade Names are not listed on formulary, allowing for generic substitution, but applying Reference Pricing & Exclusion lists.


MIMS Mims Description Active Ingredient Schedule Route of

adminDosage Form ATC Acute Quantities and

limitations

1. Central Nervous System

1.2 Sedative hypnotics

1.2.1 Benzodiazepines Brotizolam Tab 0.25 MG 5 OR TABS N05CD09 A Max Rx/5 days every 120 days

Flunitrazepam Tab 1 MG 5 OR TABS N05CD03 A Max Rx/5 days every 120 days

Flurazepam HCl Cap 15 MG 5 OR CAPS N05CD01 A Max Rx/5 days every 120 days

Flurazepam HCl Cap 30 MG 5 OR CAPS N05CD01 A Max Rx/5 days every 120 days

Loprazolam Meslyate Tab 2 MG (Base Equivalent) 5 OR TABS N05CD11 A Max Rx/5 days every

120 days

Lormetazepam Cap 0.5 MG 5 OR CAPS N05CD06 A Max Rx/5 days every 120 days

Lormetazepam Cap 1 MG 5 OR CAPS N05CD06 A Max Rx/5 days every 120 days

Lormetazepam Cap 2 MG 5 OR CAPS N05CD06 A Max Rx/5 days every 120 days

Midazolam HCl Inj 1 MG/ML (Base Equivalent) 5 IJ SOLN N05CD08 A Consumables

Midazolam HCl Inj 15 MG/3ML (Base Equivalent) 5 IJ SOLN N05CD08 A Consumables

Midazolam HCl Inj 5 MG/ML (Base Equivalent) 5 IJ SOLN N05CD08 A Consumables

Midazolam HCl Inj 50 MG/10ML (Base Equivalent) 5 IJ SOLN N05CD08 A Consumables

Midazolam Inj 1 MG/ML 5 IJ SOLN N05CD08 A Consumables

Midazolam Maleate Tab 15 MG 5 OR TABS N05CD08 A Max Rx/5 days every 120 days

Midazolam Maleate Tab 7.5 MG 5 OR TABS N05CD08 A Max Rx/5 days every 120 days

Nitrazepam Tab 5 MG 5 OR TABS N05CD02 A Max Rx/5 days every 120 days

Temazepam Cap 10 MG 5 OR CAPS N05CD07 A Max Rx/5 days every 120 days

Temazepam Cap 20 MG 5 OR CAPS N05CD07 A Max Rx/5 days every 120 days

Triazolam Tab 0.125 MG 5 OR TABS N05CD05 A Max Rx/5 days every 120 days

Triazolam Tab 0.25 MG 5 OR TABS N05CD05 A Max Rx/5 days every 120 days

2. Anaesthetics

2.2 Local Anaesthetics Lidocaine HCl Local Inj 1% 4 IJ SOLN N01BB02 A Consumables

Lidocaine HCl Local Inj 2% 4 IJ SOLN N01BB02 A ConsumablesLidocaine Inj 2% w/ Epinephrine-1:80000 4 IJ SOLN N01BB02 A Consumables

3. Analgesics

3.2. Analgesics and antipyretics

3.2 Analgesics & antipyretics Acetaminophen Cap 500 MG 0 OR CAPS N02BE01 A Max Rx/7 days & 3

Rx/ annum

Acetaminophen Effer Tab 500 MG 0 OR TBEF N02BE01 A Max Rx/7 days & 3 Rx/ annum




limitations

3.2 Analgesics & antipyretics Acetaminophen Elixir 120 MG/5ML 0 OR ELIX N02BE01 A Max 200ml/Rx & 3

Rx/ annumAcetaminophen IV Soln 10 MG/ML 3 IV SOLN N02BE01 A Consumables

Acetaminophen Soln 100 MG/ML 0 OR SOLN N02BE01 A Max 20ml/Rx & 3 Rx/annum

Acetaminophen Soluble Tab 125 MG 0 OR TBSO N02BE01 A Max Rx/7 days & 3 Rx/ annum

Acetaminophen Soluble Tab 500 MG 0 OR TBSO N02BE01 A Max Rx/7 days & 3 Rx/ annum

Acetaminophen Suppos 125 MG 2 RE SUPP N02BE01 A Max 1 op/annumAcetaminophen Suppos 250 MG 2 RE SUPP N02BE01 A Max 1 op/annum

Acetaminophen Syrup 120 MG/5ML 0 OR SYRP N02BE01 A Max 200ml/Rx & 3 Rx/ annum

Acetaminophen Tab 500 MG 0 OR TABS N02BE01 A Max Rx/7 days & 3 Rx/ annum

Acetaminophen Tab CR 650 MG 1 OR TBCR N02BE01 A Max Rx/7 days & 3 Rx/ annum

Aspirin Dispersible Tab 300 MG 0 OR TBDP N02BA01 A Max 1 fills/annumAspirin Tab 300 MG 0 OR TABS N02BA01 A Max 2 fills/annumAspirin Tab 81 MG 0 OR TBEC N02BA01 A Max 2 fills/annum

Ibuprofen Susp 100 MG/5ML 2 OR SUSP M01AE01 A Max 200ml/Rx & 3 Rx/annum

Ibuprofen Susp 100 MG/5ML 2 OR SUSP M01AE01 A Max 200ml/Rx & 3 Rx/annum

Ketorolac Tromethamine Inj 10 MG/ML 4 IJ SOLN M01AB15 A ConsumablesKetorolac Tromethamine Inj 30 MG/ML 4 IJ SOLN M01AB15 A Consumables

Ketorolac Tromethamine Tab 10 MG 4 OR TABS M01AB15 A Max Rx/7 days & 3 Rx/annum

Mefenamic Acid Cap 250 MG 3 OR CAPS M01AG01 A Max Rx/7 days & 3 Rx/annum

Mefenamic Acid Supp 125 MG 3 RE SUPP M01AG01 A Max 1 op/annum

Mefenamic Acid Susp 50 MG/5ML 3 OR SUSP M01AG01 A Max 200ml/Rx & 3 Rx/annum

Mefenamic Acid Tab 500 MG 3 OR TABS M01AG01 A Max Rx/7 days & 3 Rx/annum

3.3. Combination Analgesics

3.3 Combination Analgesics

Acetaminophen w/ Codeine & Vitamins Tab 500-10-50 MG 2 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen w/ Codeine Cap 320-8 MG 1 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen w/ Codeine Effer Tab 500-8 MG 2 OR TBEF N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen w/ Codeine Syrup 120-5 MG/5ML 1 OR SYTP N02BE51 A Max 100ml/Rx & 3

Rx/ annumAcetaminophen w/ Codeine Syrup 150-4 MG/5ML 1 OR SYRP N02BE51 A Max 100ml/Rx & 3

Rx/ annum




limitations

3.3 Combination Analgesics

Acetaminophen w/ Codeine Tab 500-10 MG 1 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen w/ Codeine Tab 500-20 MG 2 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen w/ Codeine Tab 500-8 MG 2 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Diphenhydramine-Caff-Cod Tab 400-5-50-10 MG 2 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Doxylamine-Caff-Cod Effer Tab 450-5-50-10 MG 2 OR TBEF N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Doxylamine-Caffeine-Co-deine Cap 450-5-30-10 MG 2 OR CAPS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Doxylamine-Caffeine-Co-deine Tab 450-5-45-10 MG 2 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Doxylamine-Caffeine-Co-deine Tab 450-5-50-10 MG 2 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Meprobamate-Caff-Cod Cap 200-150-30-10 MG 5 OR CAPS N02BE71 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Meprobamate-Caff-Cod Cap 320-150-48-8 MG 5 OR CAPS N02BE71 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Meprobamate-Caff-Cod Tab 200-150-30-10 MG 5 OR TABS N02BE71 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Meprobamate-Caff-Cod Tab 320-150-32-8 MG 5 OR TABS N02BE71 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Meprobamate-Codeine Cap 400-200-8 MG 5 OR CAPS N02BE71 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Meprobamate-Codeine Tab 500-125-10 MG 5 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Phenyltoloxam-ine-Caff-Cod Tab 400-12-32-8 MG 2 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annumAcetaminophen-Promethazine w/ Codeine Syrup 120-6.5-5 MG/5ML 2 OR SYRP N02BE51 A Max 200ml/Rx & 3

Rx/ annumAcetaminophen-Promethazine w/ Codeine Syrup 120-7-5 MG/5ML 2 OR SYRP N02BE51 A Max Rx/7 days & 3

Rx/annumAPAP-Aspirin-Caffeine-Citrated Caff Pack 276-553-8-33 MG 0 OR PACK N02BA51 A Max Rx/7 days & 3

Rx/annumAPAP-Diphenhydramine-PB-Caff-Cod Tab 400-5-8-50-10 MG 2 OR TABS N02BE71 A Max Rx/7 days & 3

Rx/annumAPAP-Na Salicylate-Aloin-Buchu Tab 97.19-48.59-0.65-32.4 MG 0 OR TABS N02BA51 A Max Rx/7 days & 3

Rx/annumASA-APAP-Meprobamate-Caff-Cod Tab 200-200-150-30-10 MG 5 OR TABS N02BA51 A Max Rx/7 days & 3

Rx/annumAspirin w/ Codeine Dispersible Tab 500-8 MG 2 OR TBDP N02BA51 A Max Rx/7 days & 3

Rx/annumAspirin-Acetaminophen w/ Codeine Tab 250-250-10 MG 2 OR TABS N02BA51 A Max Rx/7 days & 3

Rx/annumAspirin-Acetaminophen-Caffeine Powd Pack 453.6-324-64.8 MG 0 OR POWD N02BA51 A Max Rx/7 days & 3

Rx/annumAspirin-Acetaminophen-Caffeine Tab 226-160-32 MG 0 OR TABS N02BA51 A Max Rx/7 days & 3



Rx/annum

Aspirin-Caffeine Tab 325-22 MG 0 OR TABS N02BA51 A Max Rx/7 days & 3 Rx/annum




limitations

3.3 Combination Analgesics Aspirin-Caffeine Tab 400-22.7 MG 0 OR TABS N02BA51 A Max Rx/7 days & 3

Rx/annum



Ibuprofen-Acetaminophen Cap 200-250 MG 2 OR CAPS M01AE51 A Max Rx/7 days & 3

Rx/annumIbuprofen-Acetaminophen Susp 100-125 MG/5ML 2 OR SUSP M01AE51 A Max 100ml/Rx & 3

Rx/ annumIbuprofen-Acetaminophen Tab 200-350 MG 2 OR TABS M01AE51 A Max Rx/7 days & 3

Rx/annumIbuprofen-Acetaminophen Tab 400-325 MG 3 OR TABS M01AE51 A Max Rx/7 days & 3

Rx/annumIbuprofen-Acetaminophen-Codeine Cap 200-250-10 MG 3 OR CAPS M01AE51 A Max Rx/7 days & 3

Rx/annumIbuprofen-Acetaminophen-Codeine Susp 200-250-10 MG/10ML 3 OR SUSP M01AE51 A Max 100ml/Rx & 3

Rx/ annumIbuprofen-Acetaminophen-Codeine Tab 200-350-10 MG 3 OR TABS M01AE51 A Max Rx/7 days & 3

Rx/annum

Ibuprofen-Codeine Tab 200-10 MG 2 OR TABS M01AE51 A Max Rx/7 days & 3 Rx/annum

Ibuprofen-Codeine Tab 200-12.5 MG 2 OR TABS M01AE51 A Max Rx/7 days & 3 Rx/annum

Mephenesin-Acetaminophen Tab 150-500 MG 2 OR TABS N02BE51 A Max Rx/7 days & 3

Rx/annum

Orphenadrine w/ APAP Tab 35-450 MG 2 OR TABS M03BC51 A Max Rx/7 days & 3 Rx/annum

Tramadol-Acetaminophen Tab 37.5-325 MG 5 OR TABS N02AX52 A Max Rx/7 days & 3

Rx/annum

4. Musculo-Skeletal Agents

4.1 Non-Steroidal Anti-Inflammatory Agents

4.1.1 COX Inhibitors Diclofenac Potassium Tab 12.5 MG 2 OR TABS M01AB05 A Max Rx/5 days & 2 Rx/annum

Diclofenac Potassium Tab 50 MG 2 OR TABS M01AB05 A Max Rx/5 days & 2 Rx/annum

Diclofenac Potassium Tab Disp 50 MG 3 OR PACK M01AB05 A Max Rx/5 days & 2 Rx/annum

Diclofenac Sodium Cap SR 24HR 100 MG 3 OR CP24 M01AB05 A Max Rx/5 days & 2

Rx/annumDiclofenac Sodium Cap SR 24HR 75 MG 3 OR CP24 M01AB05 A Max Rx/5 days & 2

Rx/annumDiclofenac Sodium IM Inj Soln 25 MG/ML 3 IJ SOLN M01AB05 A Consumables

Diclofenac Sodium Suppos 100 MG 3 RE SUPPS M01AB05 A Max 1 op/Rx & 2 Rx/annum

Diclofenac Sodium Suppos 12.5 MG 3 RE SUPPS M01AB05 A Max 1 op/Rx & 2 Rx/annum

Diclofenac Sodium Suppos 25 MG 3 RE SUPPS M01AB05 A Max 1 op/Rx & 2 Rx/annum

Diclofenac Sodium Susp 15 MG/ML 3 OR SUSP M01AB05 A ConsumablesDiclofenac Sodium Tab Delayed Release 25MG 2 OR TBEC M01AB05 A Max Rx/5 days & 2

Rx/annumDiclofenac Sodium Tab Delayed Release 50 MG 2 OR TBEC M01AB05 A Max Rx/5 days & 2

Rx/annum




limitations

4.1.1 COX Inhibitors Diclofenac Sodium Tab Disp 50 MG 3 OR TBDP M01AB05 A Max Rx/5 days & 2 Rx/annum

Diclofenac Sodium Tab SR 24HR 100 MG 3 OR TB24 M01AB05 A Max Rx/5 days & 2

Rx/annumDiclofenac Sodium Tab SR 24HR 75 MG 3 OR TB24 M01AB05 A Max Rx/5 days & 2

Rx/annumDiclofenac w/ Misoprostol EC Tab 50-0.2 MG 4 OR TABS M01AB55 A Max Rx/5 days & 2

Rx/annumDiclofenac w/ Misoprostol Tab CR 75-0.2 MG 4 OR TABS M01AB55 A Max Rx/5 days & 2

Rx/annum

Ibuprofen Cap 200 MG 1 OR CAPS M01AE01 A Max Rx/5 days & 2 Rx/annum

Ibuprofen Cap 400 MG 1 OR CAPS M01AE01 A ConsumablesIbuprofen Lysine IV Soln 10 MG/2ML (Base Equivalent) 3 IV SOLN C01EB16 A Max Rx/5 days & 2

Rx/annum

Ibuprofen Tab 200 MG 3 OR TABS M01AE01 A Max Rx/5 days & 2 Rx/annum



Ibuprofen Tab CR 800 MG 3 OR TBCR M01AE01 A Max Rx/5 days & 2 Rx/annum

Indomethacin Cap 25 MG 3 OR CAPS M01AE01 A Max Rx/5 days & 2 Rx/annum

Indomethacin Cap 50 MG 3 OR CAPS M01AE01 A Max 1 op/Rx & 2 Rx/annum

Indomethacin Suppos 100 MG 3 RE SUPP M01AE01 A Max Rx/5 days & 2 Rx/annum

Ketoprofen Cap SR 24HR 200 MG 3 OR CP24 M01AE03 A Consumables

Lornoxicam Inj 4 MG/ML 3 IJ SOLN M01AC05 A Max Rx/5 days & 2 Rx/annum

Lornoxicam Tab 4 MG 3 OR TABS M01AC05 A Max Rx/5 days & 2 Rx/annum

Lornoxicam Tab 8 MG 3 OR TABS M01AC05 A Max Rx/5 days & 2 Rx/annum

Naproxen Sodium Cap 220 MG 2 OR CAPS M01AE02 A Max Rx/5 days & 2 Rx/annum

Naproxen Sodium Tab 275 MG 3 OR TABS M01AE02 A Max Rx/5 days & 2 Rx/annum

Naproxen Sodium Tab 550 MG 3 OR TABS M01AE02 A Max 1 op/Rx & 2 Rx/annum

Naproxen Suppos 500 MG 3 RE SUPPS M01AE02 A

Naproxen Tab 250 MG 3 OR TABS M01AE02 A Max Rx/5 days & 2 Rx/annum

Naproxen Tab 500 MG 3 OR TABS M01AE02 A Max Rx/5 days & 2 Rx/annum

Naproxen Tab EC 250 MG 3 OR TBEC M01AE02 A Max Rx/5 days & 2 Rx/annum

Naproxen Tab EC 500 MG 3 OR TBEC M01AE02 A Max Rx/5 days & 2 Rx/annum

Piroxicam Betadex Tab 20 MG (Base Equiv) 3 OR TABS M01AC01 A Max Rx/5 days & 2

Rx/annum

Piroxicam Cap 10 MG 2 OR TABS M01AC01 A Max Rx/5 days & 2 Rx/annum




limitations

4.1.1 COX Inhibitors Piroxicam Cap 20 MG 2 OR TABS M01AC01 A Max Rx/5 days & 2 Rx/annum

Piroxicam Tab Disp 20 MG 3 OR TBDP M01AC01 A Max Rx/5 days & 2 Rx/annum

Sulindac Tab 200 MG 3 OR TABS M01AB02 A Max Rx/5 days & 2 Rx/annum

4.1.2 Selective COX2 Inhibitors

Meloxicam IM Inj 10 MG/ML 3 IM SOLN M01AC06 A Consumables

Meloxicam Tab 15 MG 3 OR TABS M01AC06 A Max Rx/5 days & 2 Rx/annum

Meloxicam Tab 7.5 MG 3 OR TABS M01AC06 A Max Rx/5 days & 2 Rx/annum

11. Ear, Nose and Throat

11.3 Mouth and throat preparations

11.3 Mouth and throat preparations Benzocaine Lozenge 10 MG 1 MT LOZG R02AA A Max 20/Rx & 4 Rx/

annumBenzocaine-Cetylpyridinium Soln 1-0.1% 1 MT SOLN A01AD A Max 1 op/annum

Benzocaine-Chlorhexidine Gluconate Soln 1 MT SOLN R02AA A Max 200ml/annum

Benzydamine HCl Lozg 3 MG 1 MT LOZG A01AD02 A Max 20/Rx & 4 Rx/annum

Benzydamine HCl Soln 0.15% 1 MT SOLN A01AD02 A Max 1 op/Rx & 2 Rx/annum

Benzydamine-Cetylpyridnium Lozg 3-1.33 MG 1 MT LOZG R02AA A Max 24/Rx & 4 Rx/

annumBenzydamine-Chlorhexidine Gluconate Soln 0.15-0.12% 1 MT SOLN A01AD02 A Max 1 op/Rx & 2 Rx/

annumCetylpyridinium Chloride Liquid 0.05% 0 MT SOLN R02AA06 A Max 200ml/annumCetylpyridinium-Benzocaine Lozenge 1.5-10 MG 1 MT LOZG R02AA A Max 20/Rx & 4 Rx/

annumCetylpyridinium-Benzocaine-Lozenge2-10MG 1 MT LOZG R02AA A Max 20/Rx & 4 Rx/

annumChlorhexidine Gluconate Soln 0.2% 0 MT SOLN R02AA05 A Max 200ml/annumDequalinium Chloride-Lidocaine Mouth Paint 40-175 MG/10ML 1 MT LIQD R02AA02 A Max 1 op/annum

Dibucaine-Benzocaine-Cetylpyridini-um-Benzyl Alcohol Soln 1 MT SOLN R02AA A Max 200ml/annum

Flurbiprofen Lozenge 8.75 MG 0 MT LOZG R02AA A Max 1 op/Rx & 2 Rx/annum

Hexetidine Soln 0.1% 0 MT SOLN A01AB12 A Max 200ml/annum

Menthol Lozenge 1 MG 0 MT LOZG R02AA A Max 20/Rx & 4 Rx/annum

Miconazole Gel 2% (Mouth-Throat) 2 MT GEL A01AB09 A Max 1 op/annumOrabase Paste 0 MT PSTE A01AD A Max 1 op/annumPhenol Soln 0.5% 0 MT SOLN R02AA19 A Max 1 op/annumPovidone-Iodine Mouthwash 1% 0 MT SOLN R02AA15 A Max 200ml/annumTetracaine HCl Ointment 0.5% 1 MT OINT A01AD A Max 1 op/annumZinc Gluconate w/ Vitamin C Lozenge 25-50 MG 0 MT LOZG A01AD11 A Max 20/Rx & 4 Rx/

annum

18. Anti-Microbials




limitations

18.1. Beta-lactams

18.1.1 Penicillins Amoxicillin & K Clavulanate For IV Soln 1000-200 MG 4 IV SOLR J01CR02 A Consumables

Amoxicillin & K Clavulanate For IV Soln 500-100 MG 4 IV SOLR J01CR02 A Consumables

Amoxicillin & K Clavulanate For Susp 125-31.25 MG/5ML 4 OR SUSR J01CR02 A Max 4 fills/annum



Amoxicillin & K Clavulanate For Susp 400-57 MG/5ML 4 OR SUSR J01CR02 A Max 4 fills/annum


Amoxicillin & K Clavulanate Tab 250-125 MG 4 OR TABS J01CR02 A Max 4 fills/annum



Amoxicillin & K Clavulanate Tab SR 12HR 1000-62.5 MG 4 OR TB12 J01CR02[ A Max 4 fills/annum

Amoxicillin (Trihydrate) Cap 250 MG 4 OR CAPS J01CA04 A Max 4 fills/annumAmoxicillin (Trihydrate) Cap 500 MG 4 OR CAPS J01CA04 A Max 4 fills/annumAmoxicillin (Trihydrate) For Susp 100 MG/ ML 4 OR SUSR J01CA04 A Max 4 fills/annum

Amoxicillin (Trihydrate) For Susp 125 MG/5ML 4 OR SUSR J01CA04 A Max 4 fills/annum

Amoxicillin (Trihydrate) For Susp 250 MG/5ML 4 OR SUSR J01CA04 A Max 4 fills/annum

Amoxicillin-Floxacillin Cap 250-250 MG 4 OR CAPS J01CR50 A Max 4 fills/annum

Amoxicillin-Floxacillin For Susp 125-125 MG/5ML 4 OR SUSR J01CR50 A Max 4 fills/annum

Ampicillin Cap 250 MG 4 OR CAPS J01CA01 A Max 4 fills/annumAmpicillin For Susp 125 MG/5ML 4 OR SUSR J01CA01 A Max 4 fills/annumAmpicillin Sodium For Inj 250 MG 4 IJ SOLR J01CA01 A ConsumablesAmpicillin Sodium For Inj 500 MG 4 IJ SOLR J01CA01 A ConsumablesAmpicillin-Cloxacillin Cap 250-250 MG 4 OR CAPS J01CA51 A Max 4 fills/annumAmpicillin-Cloxacillin For Inj 125-125 MG 4 IJ SOLR J01CA51 A Consumables

Ampicillin-Cloxacillin For Inj 250-250 MG 4 IJ SOLR J01CA51 A Consumables

Ampicillin-Cloxacillin For Inj 500-500 MG 4 IJ SORL J01CA51 A Consumables

Ampicillin-Cloxacillin For Susp 125-125 MG/5ML 4 OR SUSR J01CA51 A Max 4 fills/annum

Cloxacillin Sodium Cap 250 MG 4 OR CAPS J01CF02 A Max 4 fills/annum

Cloxacillin Sodium Cap 500 MG 4 OR CAPS J01CF02 A Max 4 fills/annumCloxacillin Sodium For Inj 250 MG 4 IJ SOLR J01CF02 A Consumables




limitations

18.1.1 Penicillins Cloxacillin Sodium For Inj 500 MG 4 IJ SOLR J01CF02 A ConsumablesFloxacillin Sodium Cap 250 MG 4 OR CAPS J01CF05 A Max 4 fills/annumPenicillin G Benzathine For Intramuscular Susp 1200000 Unit 4 IM SUSR J01CE08 A Consumables

Penicillin G Benzathine For Intramuscular Susp 2400000 Unit 4 IM SUSR J01CE08 A Consumables

Penicillin G Procaine Intramuscular Susp 300000 Unit/ML 4 IM SUSR J01CE09 A Consumables

Penicillin G Sodium For Inj 1000000 Unit 4 IJ SUSR J01CE01 A ConsumablesPenicillin G Sodium For Inj 5000000 Unit 4 IJ SUSR J01CE01 A ConsumablesPenicillin V Potassium For Soln 125 MG/5ML 4 OR SOLR J01CE02 A Max 4 fills/annum

Penicillin V Potassium Tab 250 MG 4 OR TABS J01CE02 A Max 4 fills/annumPiperacillin Sodium-Tazobactam Sodium For Inj 4-0.5 GM 4 IV SOLR J01CR05 A Consumables

18.1.2 Cephalosporins Cefaclor For Susp 187 MG/5ML 4 OR SUSR J01DC04 A Max 2 fills/annumCefaclor For Susp 375 MG/5ML 4 OR SUSR J01DC04 A Max 2 fills/annumCefaclor Monohydrate Tab SR 12HR 375 MG 4 OR TB12 J01DC04 A Max 2 fills/annum

Cefadroxil Cap 500 MG 4 OR CAPS J01DB05 A Max 2 fills/annumCefadroxil Effer Tab 250 MG 4 OR TBEF J01DB05 A Max 2 fills/annumCefadroxil For Susp 250 MG/5ML 4 OR SUSR J01DB05 A Max 2 fills/annumCefadroxil For Susp 500 MG/5ML 4 OR SUSR J01DB05 A Max 2 fills/annumCefazolin Sodium For Inj 1 GM 4 IJ SOLR J01DB04 A ConsumablesCefazolin Sodium For Inj 500 MG 4 IJ SORL J01DB04 A ConsumablesCefazolin Sodium For IV Soln 1 GM 4 IV SORL J01DB04 A ConsumablesCefepime HCl For Inj 1 GM 4 IJ SOLN J01DE01 A ConsumablesCefepime HCl For Inj 2 GM 4 IJ SOLN J01DE01 A ConsumablesCefepime HCl For Inj 500 MG 4 IJ SOLN J01DE01 A ConsumablesCefixime Tab 400 MG 4 OR TABS J01DD08 A Max 2 fills/annumCefotaxime Sodium For Inj 1 GM 4 IJ SOLR J01DD01 A ConsumablesCefotaxime Sodium For Inj 500 MG 4 IJ SOLR J01DD01 A ConsumablesCefoxitin Sodium For Inj 1 GM 4 IJ SOLR J01DD01 A ConsumablesCefpodoxime Proxetil For Susp 40 MG/5ML 4 OR SUSR J01DD13 A Max 2 fills/annum

Cefpodoxime Proxetil Tab 100 MG 4 OR TABS J01DD13 A Max 2 fills/annumCefpodoxime Proxetil Tab 200 MG 4 OR TABS J01DD13 A Max 2 fills/annumCefprozil For Susp 125 MG/5ML 4 OR SUSR J01DC10 A Max 2 fills/annumCefprozil For Susp 250 MG/5ML 4 OR SUSR J01DC10 A Max 2 fills/annumCefprozil Tab 250 MG 4 OR TABS J01DC10 A Max 2 fills/annumCefprozil Tab 500 MG 4 OR TABS J01DC10 A Max 2 fills/annumCeftazidime For Inj 1 GM 4 IJ SOLR J01DD02 A ConsumablesCeftazidime For Inj 2 GM 4 IJ SOLR J01DD02 A ConsumablesCeftazidime For Inj 500 MG 4 IJ SOLR J01DD02 A ConsumablesCeftriaxone Sodium For Inj 1 GM 4 IJ SOLR J01DD04 A ConsumablesCeftriaxone Sodium For Inj 2 GM 4 IJ SOLR J01DD04 A ConsumablesCeftriaxone Sodium For Inj 250 MG 4 IJ SOLR J01DD04 A ConsumablesCeftriaxone Sodium For Inj 500 MG 4 IJ SOLR J01DD04 A ConsumablesCeftriaxone Sodium For IV Soln 2 GM 4 IJ SOLR J01DD04 A ConsumablesCefuroxime Axetil For Susp 125 MG/5ML 4 OR SUSR J01DC02 A Max 2 fills/annum




limitations

18.1.2 Cephalosporins Cefuroxime Axetil Tab 125 MG 4 OR TABS J01DC02 A Max 2 fills/annumCefuroxime Axetil Tab 250 MG 4 OR TABS J01DC02 A Max 2 fills/annumCefuroxime Axetil Tab 500 MG 4 OR TABS J01DC02 A Max 2 fills/annumCefuroxime Sodium For Inj 1.5 GM 4 IJ SOLR J01DC02 A ConsumablesCefuroxime Sodium For Inj 250 MG 4 IJ SOLR J01DC02 A ConsumablesCefuroxime Sodium For Inj 750 MG 4 IJ SOLR J01DC02 A ConsumablesCephalexin Cap 250 MG 4 OR CAPS J01DB01 A Max 2 fills/annumCephalexin For Susp 125 MG/5ML 4 OR SUSR J01DB01 A Max 2 fills/annumCephalexin For Susp 250 MG/5ML 4 OR SUSR J01DB01 A Max 2 fills/annumCephalexin Tab 250 MG 4 OR TABS J01DB01 A Max 2 fills/annumCephalexin Tab 500 MG 4 OR TABS J01DB01 A Max 2 fills/annumCephradine Cap 250 MG 4 OR CAPS J01DB09 A Max 2 fills/annumCephradine For Inj 1 GM 4 IJ SOLR J01DB09 A ConsumablesCephradine For Inj 500 MG 4 IJ SORL J01DB09 A ConsumablesImipenem-Cilastatin Intravenous For Soln 500 MG 4 IV INJ J01DH51 A Consumables

18.1.3 Others None listed18.2. Erythromycin and other macrolides

18.2 Erythromycin and other macrolides

Azithromycin Cap 250 MG 4 OR CAPS J01FA10 A Max 2 fills/annumAzithromycin Extended Release For Oral Susp 2 GM 4 OR GRAN J01FA10 A Max 2 fills/annum

Azithromycin For Susp 200 MG/5ML 4 OR SUSR J01FA10 A Max 2 fills/annumAzithromycin IV For Soln 500 MG 4 IV SOLR J01FA10 A ConsumablesAzithromycin Tab 500 MG 4 OR TABS J01FA10 A Max 2 fills/annumClarithromycin For IV Soln 500 MG 4 IV SOLR J01FA09 A ConsumablesClarithromycin For Susp 125 MG/5ML 4 OR SUSR J01FA09 A Max 2 fills/annumClarithromycin For Susp 250 MG/5ML 4 OR SUSR J01FA09 A Max 2 fills/annumClarithromycin Tab 250 MG 4 OR TABS J01FA09 A Max 2 fills/annumClarithromycin Tab 500 MG 4 OR TABS J01FA09 A Max 2 fills/annumClarithromycin Tab SR 24HR 500 MG 4 OR TB24 J01FA09 A Max 2 fills/annumErythromycin Estolate Cap 250 MG 4 OR CAPS J01FA01 A Max 4 fills/annumErythromycin Estolate Susp 125 MG/5ML 4 OR SUSP J01FA01 A Max 4 fills/annum

Erythromycin Estolate Susp 250 MG/5ML 4 OR SUSP J01FA01 A Max 4 fills/annum

Erythromycin Lactobionate For Inj 1000 MG 4 IV SOLR J01FA01 A Consumables

Erythromycin Stearate Cap 250 MG 4 OR CAPS J01FA01 A Max 4 fills/annumErythromycin Stearate Tab 250 MG 4 OR TABS J01FA01 A Max 4 fills/annumRoxithromycin Tab 150 MG 4 OR TABS J01FA06 A Max 2 fills/annumRoxithromycin Tab 300 MG 4 OR TABS J01FA06 A Max 2 fills/annumTelithromycin Tab 400 MG 4 OR TABS J01FA15 A Max 2 fills/annum

18.3. Aminoglycosides

18.3 Aminoglycosides Gentamicin Sulfate Inj 10 MG/ML 4 IJ SOLN J01GB03 A ConsumablesGentamicin Sulfate Inj 40 MG/ML 4 IJ SOLN J01GB03 A Consumables




limitations

18.4. Tetracyclines

18.4 Tetracyclines Doxycycline Hyclate Cap 100 MG 4 OR CAPS J01AA02 A Max 4 fills/annumDoxycycline Hyclate Cap 50 MG 4 OR CAPS J01AA02 A Max 4 fills/annumDoxycycline Hyclate Cap DR Particles 200 MG 4 OR CPEP J01AA02 A Max 4 fills/annum

Doxycycline Hyclate Tab 100 MG 4 OR TABS J01AA02 A Max 4 fills/annumDoxycycline Monohydrate Tab 100 MG 4 OR TABS J01AA02 A Max 4 fills/annumLymecycline Cap 150 MG 4 OR CAPS J01AA04 A Max 4 fills/annumLymecycline Cap 300 MG 4 OR CAPS J01AA04 A Max 4 fills/annumMinocycline HCl Cap 100 MG 4 OR CAPS J01AA08 A Max 4 fills/annumMinocycline HCl Cap 50 MG 4 OR CAPS J01AA08 A Max 4 fills/annumMinocycline HCl Tab 50 MG 4 OR TABS J01AA08 A Max 4 fills/annumOxytetracycline HCl Cap 250 MG 4 OR CAPS J01AA06 A Max 4 fills/annumTetracycline 250 MG-Nystatin 250,000 Unit w/ Vitamins Cap 4 OR CAPS J01AA20 A Max 4 fills/annum

18.5. Chloramphenicols

18.5 Chloramphenicols Chloramphenicol Cap 250 MG 4 OR CAPS J01BA01 A Max 4 fills/annumChloramphenicol Sodium Succinate For IV Inj 1 GM 4 IV SOLR J01BA01 A Consumables

Chloramphenicol Susp 125 MG/5ML 4 OR SUSP J01BA01 A Max 4 fills/annum18.6. Sulphonamides and combinations

18.6 Sulphonamides and combinations

Sulfamethoxazole-Trimethoprim IV Soln 400-80 MG/5ML 4 IV SOLN J01EE01 A Consumables

Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML 4 OR SUSP J01EE01 A Max 4 fills/annum

Sulfamethoxazole-Trimethoprim Tab 400-80 MG 4 OR TABS J01EE01 A Max 4 fills/annum

Sulfamethoxazole-Trimethoprim Tab 800-160 MG 4 OR TABS J01EE01 A Max 4 fills/annum

18.7 Quinolones

18.7 Quinolones Ciprofloxacin For Oral Susp 250 MG/5ML (5%) (5 GM/100ML) 4 OR SUSP J01MA02 A Max 4 fills/annum

Ciprofloxacin HCl Tab 250 MG (Base Equiv) 4 OR TABS J01MA02 A Max 4 fills/annum



Ciprofloxacin Lactate IV Soln 2 MG/ML 4 IV SOLN J01MA02 A ConsumablesCiprofloxacin-Ciprofloxacin HCl Tab SR 24HR 1000 MG(Base Eq) 4 OR TB24 J01MA02 A Max 4 fills/annum

Ciprofloxacin-Ciprofloxacin HCl Tab SR 24HR 500 MG (Base Eq) 4 OR TB24 J01MA02 A Max 4 fills/annum

Gemifloxacin Mesylate Tab 320 MG (Base Equiv) 4 OR TABS J01MA15 A Max 4 fills/annum

Levofloxacin IV Soln 5 MG/ML 4 IV SOLN J01MA12 A ConsumablesLevofloxacin Tab 250 MG 4 OR TABS J01MA12 A Max 4 fills/annumLevofloxacin Tab 500 MG 4 OR TABS J01MA12 A Max 4 fills/annumLevofloxacin Tab 750 MG 4 OR TABS J01MA12 A Max 4 fills/annumMoxifloxacin HCl 400 MG/250ML in Sodium Chloride 0.8% Inj 4 IV SOLN J01MA14 A Consumables




limitations

18.7 Quinolones Moxifloxacin HCl Tab 400 MG (Base Equiv 4 OR TABS J01MA14 A Max 4 fills/annum

Norfloxacin Tab 400 MG 4 OR TABS J01MA06 A Max 4 fills/annumOfloxacin IV Soln 200 MG/100ML 4 IV SOLN J01MA01 A ConsumablesOfloxacin Tab 200 MG 4 OR TABS J01MA01 A Max 4 fills/annumOfloxacin Tab 400 MG 4 OR TABS J01MA01 A Max 4 fills/annum

18.9. Other anti-bacterial agents

18.9 Other anti-bacterial agents

Clindamycin HCl Cap 150 MG 4 OR CAPS J01FF01 A Max 2 fills/annumClindamycin Phosphate Inj 600 MG/4ML 4 IJ SOLN J01FF01 A Consumables

Fusidate Sodium IV For Inj 500 MG 4 IV SOLR J01XC01 A ConsumablesFusidate Sodium Susp 175 MG/5ML 4 OR SUSP J01XC01 A Max 2 fills/annumFusidate Sodium Tab 250 MG 4 OR TABS J01XC01 A Max 2 fills/annumLincomycin HCl Inj 300 MG/ML 4 IM SOLN J01FF02 A ConsumablesLinezolid For Susp 100 MG/5ML 4 OR SUSP J01XX08 A Max 2 fills/annumLinezolid IV Soln 2 MG/ML 4 IV SOLN J01XX08 A ConsumablesLinezolid Tab 600 MG 4 OR TABS J01XX08 A Max 2 fills/annumTeicoplanin For Inj 200 MG 4 IJ SOLR J01XA02 A ConsumablesTeicoplanin For Inj 400 MG 4 IVIJIV SOLR J01XA02 A ConsumablesTigecycline For IV Soln 50 MG 4 IV SOLR J01AA A ConsumablesVancomycin HCl For Inj 1000 MG 4 IV SOLR J01XA01 A ConsumablesVancomycin HCl For Inj 500 MG 4 IV SOLR J01XA01 A Consumables

18.10. Anti-fungal agents

18.10 Anti-fungal agents Amphotericin B For Inj 50 MG 4 IV SOLR J02AA01 A ConsumablesAmphotericin B Liposome IV For Susp 50 MG 4 IV SOLR A07AA07 A Consumables

Caspofungin Acetate For IV Soln 50 MG 4 IV SOLR J02AX04 A ConsumablesCaspofungin Acetate For IV Soln 70 MG 4 IV SOLR J02AX04 A ConsumablesClotrimazole Troche 10 MG 4 MT LOZG G01AF02 A Max 2 fills/annumFluconazole Cap 150 MG 4 OR CAPS J02AC01 A Max 2 fills/annumFluconazole Cap 200 MG 4 OR CAPS J02AC01 A Max 1 fill/annumFluconazole Cap 50 MG 4 OR CAPS J02AC01 A Max 1 fill/annum

Fluconazole For Susp 10 MG/ML 4 OR SUSP J02AC01 A Max 100ml/RX & 2 RX/annum

Fluconazole For Susp 40 MG/ML 4 OR SUSP J02AC01 A Max 100ml/RX & 2 RX/annum

Fluconazole Inj 2 MG/ML 4 IV SOLN J02AC01 A ConsumablesGriseofulvin Microsize Tab 125 MG 4 OR TABS D01BA01 A Max 2 fills/annumGriseofulvin Microsize Tab 500 MG 4 OR TABS D01BA01 A Max 2 fills/annumItraconazole Cap 100 MG 4 OR CAPS J02AC02 A Max 2 fills/annumItraconazole Oral Soln 10 MG/ML 4 OR SOLN J02AC02 A Max 2 fills/annumKetoconazole Tab 200 MG 4 OR TABS J02AB02 A Max 2 fills/annumNystatin Susp 100000 Unit/ML 4 MT SUSP A07AA02 A Max 2 fills/annumPosaconazole Susp 40 MG/ML 4 OR SUSP J02AC04 A Max 2 fills/annum

18.11. Anti-protozoal agents


Metronidazole Cap 200 MG 4 OR CAPS J01XD01 A Max 3 fills/annumMetronidazole IV Soln 5 MG/ML 4 IV SOLN J01XD01 A ConsumablesMetronidazole Supp 1 GM 4 RE SUPP J01XD01 A Max 3 fills/annum




limitations


Metronidazole Supp 500 MG 4 RE SUPP J01XD01 A Max 3 fills/annumMetronidazole Susp 200 MG/5ML 4 OR SUSP J01XD01 A Max 3 fills/annumMetronidazole Tab 200 MG 4 OR TABS J01XD01 A Max 3 fills/annumMetronidazole Tab 400 MG 4 OR TABS J01XD01 A Max 3 fills/annum

19. Endocrine System

19.5. Corticosteroids

19.5 Corticosteroids Betamethasone Dipropionate Inj 5 MG/ML 4 INJ SOLN H02AB01 A Consumables

Betamethasone Sod Phosphate & Acetate Inj Susp 6 (3-3) MG/ML 4 INJ SOLN H02AB01 A Consumables

Betamethasone Sodium Phosphate Inj 4 MG/ML (3MG/ML Base Eq) 4 INJ SOLN H02AB01 A Consumables

Betamethasone Syrup 0.6 MG/5ML 4 OR SYRP H02AB01 A Max 3 fills/annumBetamethasone Tab 0.5 MG 4 OR TABS H02AB01 A Max 3 fills/annumBetamethasone-Dexchlorpheniramine Syrup 0.25-2 MG/5ML 4 OR SYRP H02AB01 A Max 3 fills/annum

Betamethasone-Dexchlorpheniramine Tab 0.25-2 MG 4 OR TABS H02AB01 A Max 3 fills/annum

Dexamethasone Sodium Phosphate Inj 4 MG/ML 4 INJ SOLN H02AB02 A Consumables

Fludrocortisone Acetate Tab 0.1 MG 4 OR TABS H02AB02 A Max 3 fills/annumHydrocortisone Sodium Succinate For Inj 100 MG 4 IJ SOLR H02AB09 A Consumables

Hydrocortisone Sodium Succinate For Inj 500 MG 4 IJ SOLR H02AB09 A Consumables

Methylprednisolone Acetate Inj Susp 40 MG/ML 4 IM SUSP H02AB04 A Consumables

Methylprednisolone Sodium Succinate For Inj 125 MG 4 IJ SOLR H02AB04 A Consumables

Methylprednisolone Sodium Succinate For Inj 40 MG 4 IJ SOLR H02AB04 A Consumables

Methylprednisolone Sodium Succinate For IV Soln 1000 MG 4 IV SOLR H02AB04 A Consumables

Methylprednisolone Tab 16 MG 4 OR TABS H02AB04 A Max 3 fills/annumMethylprednisolone Tab 4 MG 4 OR TABS H02AB04 A Max 3 fills/annumPrednisolone Syrup 15 MG/5ML (USP Solu-tion Equivalent) 4 OR SYRP H02AB06 A Max 3 fills/annum

Prednisone Conc 5 MG/ML 4 OR SOLN H02AB07 A Max 3 fills/annumPrednisone Tab 20 MG 4 OR TABS H02AB07 A Max 3 fills/annumPrednisone Tab 5 MG 4 OR TABS H02AB07 A Max 3 fills/annumPrednisone Tab 50 MG 4 OR TABS H02AB07 A Max 3 fills/annum

Disclaimer

Please note that the formulary will be reviewed regularly by clinical and pharmaceutical advisors to ensure it complies with the latest industry norms for the treatment of these conditions. GEMS reserves the right to change medicine on the formulary when important information comes to light that requires us to do so e.g. new finding regarding the safety of a drug.


06 Pre-authorisation

• In all cases where pre-authorisation are required as specified earlier and per option in this guide please complete the relevant sections of the “Dental Report for Registration, Pre-notification and Pre-authorisation Form” and submit to the Scheme prior to the commencement of treatment.

Note: Should you be unsure as to whether 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: Tooth charting on the form is not necessary for pre-authorisation purposes (charting only needs to be completed at the patient’s FIRST visit to the practice in association with code 8101).

• Orthodontic Treatment: Please submit a pre-authorisation form and treatment plan which should include the diagnosis and payment quotation for approval prior to treatment to the Scheme at [email protected] or fax to 0861 00 4367.

• Periodontal treatment: please complete the “Periodontal Treatment Pre-authorisation Form” which can be downloaded from www.gems.gov.za and submit to the Scheme.


07 Claim Procedures

Required information on claims

� Main member details such as membership number, option, name, contact details.

� Patient details, including DOB, names and identity number.

� Provider detail: BHF practice number, name, contact details.

� Diagnosis and summary of medical procedures performed, medicine dispensed, other items dispensed to patient.

� Relevant tariff codes.

� Complete list of individual laboratory codes

� Associated costs.

Rejection on claims

� If the details are incomplete the claim will be rejected.

� The clinical and laboratory codes are to be submitted together ensuring corresponding service dates, details of codes used correspond with each other and authorisation numbers attached. for laboratory codes where clinical codes require pre-authorisation.

� Self-claiming laboratories may not submit their claim without confirmation with the dentist that the clinical delivery was completed.

� Any other procedures done outside the scope of benefit will not be paid.

� All claims from non-network dentists on Sapphire and Beryl options except emergency consultations (limited to one event per year) will not be funded.

� All claims requiring pre-authorisation. If no valid pre-authorisation exists, the claim will be rejected.


08 Member verification and validationVerification on benefits

• Please ensure available benefit codes and tariff value is verified with the Scheme where unsure.

• The healthcare service provider is required to verify membership details and confirm the identity of the patient.

• The Scheme will not be responsible for any payment of services excluded in accordance with Scheme or managed care rules.

• Members will be held fully liable for any claims incurred on benefits falling outside the benefit schedule.

• Benefit confirmation via pre-authorisation is required where indicated.


09 Radiology CodesRadiology codes

The following dental radiology codes are covered over and above the intra-oral radiographs as reflected in the benefit schedule.

Extra-oral Radiographs

01. Sapphire and Beryl options

The following is covered by the Sapphire and Beryl dental hospital benefit only when the removal of impacted wisdom teeth have been authorised under GA.

02. Ruby, Emerald and Onyx options

All extra oral radiographs as featured in the SADA benefit schedule apply where relevant and applicable.

Mandible Teeth and Maxilla CPT Code Description

3355 14100 X- Ray of the mandible

3361 14130 (Dental Only) X-Ray of the teeth – single quadrant

3363 14140 (Dental only) X-Ray of the teeth – more than one quadrant3365 14150 (Dental only) X- Ray of the teeth – full mouth

Code Description

8115 Panoramic X-Ray


10 Exclusions• Please refer to the summary of benefits, detailed

procedure benefit lists/schedules and general exclusions earlier in this manual pertaining to each option to ensure awareness of benefits allowed, exclusions and managed care rules that apply (e.g. pre-authorisation, number of annual events, age rules etc.)

• In instances where treatment is performed where exclusions exist or the patient’s benefits having been exceeded, the patient will be liable to self-fund such – please ensure the “Patient Consent Form” for limits exceeded (12.3) is completed by the patient and kept on file at the practice.


11 Ex-GratiaApplication for an ex-gratia consideration in the event of benefits not covered may be lodged with the Scheme in accordance with Scheme rules.


12 Dental Reportfor Registration, Pre-notification and Pre-authorisation Form



12 Periodontal Pre-authorisation Form


12 Patient Consent Form


ContactDetails

AddressPrivate Bag x782Cape Town8000

HIV Aids Helpline0860 436 736

Call Centre0860 436 777

Emergency Assistance0800 44 4367

[email protected]

Websitewww.gems.gov.za

Documents

Dental Guide - The Competition Commission of South … is your copy of the 2016 GEMS Dental Provider ... dental benefit spectrum and budgetary parameters ... Your 2016 Dental Guide