Chronic Medicine Management

What is chronic medicine?

  • It is medicine that is used on an ongoing basis to treat disabling chronic illnesses that has a negative effect on your health and quality of life.
  • Chronic medicine is usually prescribed for more than three months and helps to control a disease and its progression. In this way is prevents complications which can lead to hospitalisation.

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).

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How do I apply for chronic medicine?

  • Download a chronic medicine application here, or call GEMS on 0860 00 4367 and ask for a form to be emailed to you.
  • Your treating doctor must complete the form.
  • A separate form must be completed for each member or dependant who needs chronic medicine.
    • You only need to complete this application form once when you register on the Chronic Medicine Programme.
    • You will need to send us a new prescription every six months to ensure that you always receive your chronic medication.
    • You do not need to send a new application if your doctor changes your chronic medicine – we will only need the new prescription.
  • Ensure that your application form is completed in full.
  • Ensure that both you and your doctor have signed the application form.
  • Email the completed form and repeatable doctor's prescription to chronicdsp@gems.gov.za.
  • We will review your application and check it against the Scheme Rules to see if we can cover the medicine from your chronic medicine benefit.
  • If we approve your application, you will receive a Medicine Access Chart, listing the medicine we have agreed to pay for from your chronic medicine benefit.
  • If the medicine that we have agreed to pay for differs from the medicine your doctor has prescribed, we will attach a letter to your Medicine Access Chart that will explain the reasons for this.
  • We will also send a copy of the letter to the doctor who prescribed the medicine.
  • If we do not approve your application for chronic medicine, you and your doctor will both receive a letter explaining this decision.

How do you obtain your authorised chronic medicine?

  • Email your handwritten, repeatable prescription from your doctor for the medicines listed on the Medicine Access Chart to chronicdsp@gems.gov.za, or fax it to 0860 004 367.
  • Remember to provide your membership number and contact details together with the handwritten repeatable prescription from your doctor.
  • We will contact you to discuss how you would like to obtain your medicine. We will also ensure that you are allocated to a pharmacy of your choice, or to the GEMS Courier Pharmacy. This will help to ensure that you receive your chronic medicine every month at the delivery address of your choice.
  • If there is a change to your chronic medicine, please contact us at least one week before the next collection or delivery date.
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Does GEMS pay for all chronic medicine prescribed by doctors?

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.

For more information, please read the Chronic Medicine Guide on the GEMS website (click on For Individuals > Member Guides).