Chronic medicine is medicine used on an ongoing basis to treat disabling and/or potentially life-threatening chronic (long-lasting) illnesses, like diabetes, that have a negative effect on your health and quality of life.
Chronic medicine must be pre-authorised by the Medicine Management Department to ensure appropriateness and cost effectiveness. Some medicines are not paid in full if they are not on the Scheme's formulary or Medicine Price List (MPL). Always check with your doctor to see if the most cost effective medicine is prescribed according to the MPL and the formulary so that you do not need to pay out of your own pocket.
The Scheme will give you a choice of receiving your medicine through our Courier Pharmacy or your nearest GEMS Network pharmacy. Once you have indicated your choice; you can go and collect your medicines at your nearest Network pharmacy if that was your choice. If you chose the Courier pharmacy then they will contact you to make medicine delivery arrangements.
If you choose to obtain your approved chronic medicine from a supplier that is not a GEMS Chronic Courier or Network pharmacy, you will be liable for a 30% co-payment, which must be paid directly to the pharmacy or dispensing doctor.
Please note that the duration of authorisation varies from medicine to medicine - some medicines may be authorised on an ongoing basis, whilst others may only be authorised for a limited period. The Medicine Access Card will indicate the duration for which the medicine has been approved.
If your medicine authorisation request has been declined, a letter will be sent to you and a copy will be sent to your prescribing doctor. If further clinical information is required, your request will be reconsidered once all the relevant information has been received from your doctor. Your doctor may call 0860 436 777 for assistance.
Yes, you can appeal the decision to either reject your application for chronic medicine or to provide you with alternative medicine to the medicine your doctor prescribed. To appeal you must ask your doctor to write a clinical motivation and email it to email@example.com. Your doctor can also call us on 0860 436 777. The clinical motivation will be considered carefully by the medical advisor; however, this does not mean your appeal will be successful.
No. After a member has been contacted by the Chronic Medicine Manager and registered with either the courier pharmacy or a specific chronic network pharmacy, they will be expected to remain with that pharmacy for at least 6 months before being allowed to change. However, if a chronic member changes their home or work address, they may contact the Chronic Medicine Manager to change their registered pharmacy accordingly. Chronic members will be contacted by the Chronic Medicine Manager twice a year to confirm or re-consider whether they want their medicines delivered by the courier or collected at the pharmacy.
Chronic members, once registered with a specific chronic network pharmacy or with the courier pharmacy (as the case may be) will be expected to use only that pharmacy to obtain their authorised chronic medicines, failing which they will be liable for a 30% co-payment.
You can apply for an emergency (urgent) supply of medicine if:
When applying for emergency medicine, you are required to:
You can apply for an advance supply of chronic medicine if you need more medicine than the amount that is normally dispensed, particularly if you are travelling outside the borders of South Africa on vacation or for work. The minimum amount of advance medicine supply you can request should be equivalent to one month's stock.
When applying for an advance supply of medicine, you are required to:
GEMS will notify you if your advanced medicine supply request has been approved or provide reasons if it has been declined.
From 2010 all hospital physiotherapy will require pre-authorisation. Certain hospital admissions or procedures will automatically generate a number of physiotherapy treatment sessions without pre-authorisation being required. The number of sessions should be indicated on your pre-authorisation confirmation letter. If more sessions are required or no physiotherapy treatment sessions are indicated on the letter, please ensure that your doctor, the treating physiotherapists or the hospital case manager calls GEMS for pre-authorisation on 0860 00 4367. If there is a valid clinical reason for the required physiotherapy treatment, GEMS will approve the treatment.
No, pre-authorisation is only required for physiotherapy while you are admitted to hospital. If you are unsure please contact the call centre on 0860 00 4367.
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