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Hospital

  • You must inform the hospital that you are a GEMS member and that any hospital transfers must be authorized by calling 0800 44 4367.
  • No, pre-authorization is only required for physiotherapy while you are admitted to hospital. If you are unsure please contact the call centre on 0860 00 4367.
  • What procedure do I follow for transfers between hospitals?
  • Please ensure that your doctor, the hospital case manager or a family member informs GEMS of the extended length of stay on 0860 00 4367. If there is a valid clinical reason for the stay, GEMS will approve the extra days.
  • If a visit or admission to a hospital (out-patient or in-patient), or any scan is planned, please let us know 48 hours before the event. In the event of emergency treatment or admission to hospital over a weekend, public holiday or at night you MUST contact the Call Centre on the first working day after the incident. If you fail to get pre-authorization for a planned event or authorization on the first working day after an emergency event you will be liable to pay a R1 000 penalty.
  • The Hospital Management Programme ensures that you receive value for your benefits and appropriate, quality care while in hospital. Before you are admitted to hospital, or make an out-patient visit to a hospital, have a CT scan, MRI scan or Radio-Isotope study, you need to get a Pre-Authorization number (PAR) from GEMS by contacting 0860 00 4367.
  • If your chronic medicine changes in any way, GEMS needs to be advised. The quickest way is for the prescribing doctor or dispensing pharmacist to contact the clinical staff on the Service Provider Line (0860 436 777). The change is processed within 5 days . An updated Medicine Access Card will be mailed to you for your records. You will need to provide your Chronic Courier or the GEMS Network pharmacy (where you are registered) with the new prescription so that the medicine can be dispensed. It is not necessary to request a new Medicine Access Card if the authorized product is replaced by a generic equivalent within the same Medicine Price List (MPL) group.

General

  • If a visit or admission to a hospital (out-patient or in-patient), or any scan is planned, please let us know 48 hours before the event. In the event of emergency treatment or admission to hospital over a weekend, public holiday or at night you MUST contact the Call Centre on the first working day after the incident. If you fail to get pre-authorization for a planned event or authorization on the first working day after an emergency event you will be liable to pay a R1 000 penalty.
  • Emergency medical response by road or air to the scene of a medical emergency; Transfer by road or air to the closest, most appropriate medical facility; and Repatriation of a patient where medical intervention is required. Only dial 0800 44 4367; Give your name and the telephone number that you are calling from; Provide a brief description of what has happened and how serious the situation is; Give the address or location of the incident to assist paramedics to get there; Do not put down the phone until the person on the other side has disconnected. Important points to remember: - Please ensure that all your registered dependants are aware of this service. - Inform your child's school that he/she is a member of GEMS. Make sure your child and the school know the emergency medical service number.
  • Members must phone 0800 44 4367 in all medical emergencies.
  • Please ensure that your doctor, the hospital case manager or a family member informs GEMS of the extended length of stay on 0860 00 4367. If there is a valid clinical reason for the stay, GEMS will approve the extra days.  
  • 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.
  • You need to supply your Chronic Medicine pharmacy (either the Courier Pharmacy or GEMS Network pharmacy) with a valid doctor's prescription before they can supply you with your chronic medicine. Prescriptions have to be renewed every 6 months this is a legal requirement . A repeat prescription is valid for not more than the repeats specified on the Medicine Access Card and will be effective from the date written on the prescription. A prescription cannot be repeated for more than six months. The Chronic Medicine Manager will send you an SMS to remind you to obtain a new prescription before your old one runs out . Whether you are obtaining your medicine from the Courier Pharmacy or GEMS Network Pharmacy, you will need to send a new prescription when this is due. Your chosen Pharmacy will not send or provide you with medicine if your prescription has expired
  • GEMS is a legal entity separate from the employer and is governed by a Board of Trustees. In other words, the Board of Trustees determines the rules under which the Scheme operates, including benefits and contributions. The employer on the other hand determines the conditions of service of employees through negotiations with trade unions. In determining the conditions of service of public service employees, the employer may for example determine whether or not its employees are compelled to belong to one scheme or whether the employees have total freedom of choice of scheme. The employer also determines what level of subsidies will apply to different categories of employees or in general. Employers also play an important role in collecting contributions and ensure payment thereof to the scheme concerned.

Medicine

  • 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.
  • 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 chronicdsp@gems.gov.za. Your doctor can also call us on 0860 436 777. The clinical motivation will be considered carefully by the medical adviser; however, this does not mean your appeal will be successful.
  • 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: Obtain an Acknowledgment of Debt Form by contacting GEMS or visiting the website. . Complete the form for each beneficiary requesting an advance supply and submit it via email to enquiries@gems.gov.za or fax to 0861 00 4367. Attach the following documents to the request: Flight itinerary or a letter confirming the departure and return dates as well as a travel plan All relevant documents if using other modes of transport Prescription, if your current prescription will expire while you are still away Employment contract, if working abroad Date on which you will collect the medicine from your allocated pharmacy or the date on which you would like the Courier Pharmacy to deliver. GEMS will notify you if your advanced medicine supply request has been approved or provide reasons if it has been declined.
  • Call GEMS on 0860 00 4367 and ask for a Chronic Medicine Application Form or download one from the GEMS website at www.gems.gov.za(Click on 'Forms' under 'Members') . Your treating doctor must complete the form A separate form must be completed for each member or dependent who needs chronic medicine. You only need to complete this application form once . Ensure that your application form is completed in full . Ensure that both you and your doctor have signed the application form. . Fax the completed form to 0861 00 4367 or Email your form at chronicdsp@gems.gov.za. We will then review your application. We will check it against the Scheme Rules to see if we can cover the medicine under the chronic medicine benefit . If we approve your application, you will receive a Medicine Access Card, listing the medicine that 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 Card 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
  • 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.
  • 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 authorization varies from medicine to medicine - some medicines may be authorized on an ongoing basis, whilst others may only be authorized for a limited period. The Medicine Access Card will indicate the duration for which the medicine has been approved.
  • You can apply for an emergency (urgent) supply of medicine if: You are a new beneficiary on the Chronic Medicine Management Programme (CMMP) and you need your medicine to be authorised urgently. You are an existing beneficiary on the CMMP and require an urgent supply of medicine for a new condition, or for new or changed medicine. Obtain the Chronic Medicine Application Form by contacting GEMS or visiting the website (request your healthcare provider to complete the form on your behalf). Send the completed form via email to chronicdsp@gems.gov.za or fax to 0861 00 4367. If you want to update your chronic medicine on an existing authorisation, request your healthcare provider to phone GEMS Chronic Authorisations to change the medicine. Send the new prescription via email to enquiries@gems.gov.za or fax to 0861 00 4367. When applying for emergency medicine, you are required to: New members Obtain the Chronic Medicine Application Form by contacting GEMS or visiting the website (request your healthcare provider to complete the form on your behalf) Send the completed form via email to chronicdsp@gems.gov.za or fax to 0861 00 4367. Existing members If you want to update your chronic medicine on an existing authorisation, request your healthcare provider to phone GEMS Chronic Authorisations to change the medicine Send the new prescription via email to enquiries@gems.gov.za or fax to 0861 00 4367. GEMS will contact you once all the documents have been received.

FAQs

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