Chronic medicine must be pre-authorised by the Medicine Management department to ensure appropriateness and cost-effectiveness. It is important to note that not all medicines are paid in full as GEMS makes use of formularies and a 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 list so that you do not need to pay a co-payment from your own pocket.
For more information about the formulary and Medicine Price List, please read the Chronic Medicine Guide which is available on the GEMS website (click on For Individuals > Member Guides).
EMS will pay for chronic medicine prescribed according to the Scheme's clinical guidelines. This means that even if we cover a condition, we may NOT pay for all requested medicines from your chronic medicine benefit if it is not in line with the clinical guidelines.
Only diseases listed on the Chronic Disease List (CDL), as it appears in the Medical Schemes Act, as well as the Additional Chronic Disease List (ACDL) for each option qualify for chronic medicine benefits. Prescribed medicine not on the CDL or ACDL will be paid from your acute medicine benefit.