GEMS: Government Employees Medical Scheme

How often do I need to supply the GEMS Courier or GEMS Network pharmacy with a repeatable prescription?

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

What procedure do I follow for transfers between hospitals?

You must inform the hospital that you are a GEMS member and that any hospital transfers must be authorized by calling 0800 44 4367.

What do I do if I need an ambulance service?

Members must phone 0800 44 4367 in all medical emergencies.

What do I dial for telephonic emergencies?

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.

Do I also require pre-authorization for out of hospital physiotherapy?

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.

Why does Physiotherapy require pre-authorization and how is it going to work?

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-authorization on 0860 00 4367. If there is a valid clinical reason for the required physiotherapy treatment, GEMS will approve the treatment.

What if I stay in hospital longer than the approved length of stay?

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.

What must I ensure that I get when I apply for pre-authorization?

The unique pre-authorization number; The approved length of stay and level of care in hospital; and The approved codes.

What information must I have when I apply for pre-authorization on 0860 00 4367?

Your GEMS Membership number; The name and date of birth of the patient; The date of admission and the proposed date for the operation (if applicable); The name of the doctor and his/her telephone and practice numbers, if available; Name of the hospital with their telephone and practice numbers, if available; In the event of a CT scan, MRI procedure, or radiological procedure, the name of the radiological practice is also required; Ask your doctor for a full description of: the reason for admission to hospital or reason for scan; the associated medical diagnosis; and the planned procedure, as well as the tariff codes that the doctor intends to use. Only procedures which are covered in terms of the rules of your scheme will be covered.

When must I apply for pre-authorization?

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.

Must I do anything before going to hospital?

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.

How do I apply for advance supply of medicine?

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.

How do I apply for emergency supply of medicine?

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.

What if my authorized benefit changes?

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.

Can I change my registered Chronic Network Pharmacy at any time I want to?

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.

Can you appeal a medicine authorization?

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.

What if my chronic medicine authorization request has been declined?

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.

How do I obtain my approved chronic medicine?

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.

How do I apply for authorization of my chronic medicine?

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

What is chronic 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.

Why is my subsidy less on GEMS than with my previous scheme?

The subsidy structure implemented on 1 July 2006 included a no worse off clause that allows members to receive the highest of the rand value of their subsidy on 30 June 2006, or the subsidy per the 75% calculation (subject to applicable limits). For example, a single employee with no beneficiaries who joins GEMS will receive a subsidy of 75% of the total contribution, limited to R670. If the employee received an employer subsidy of R710.00 on 30 June 2006, the employee will continue to receive the R710.00 employer subsidy, as it is greater than the 75% calculation. Please note that the no worse off clause only applies to employees who received an employer subsidy on 30 June 2006. If no employer subsidy was received on 30 June 2006, the employee will only qualify for a subsidy equal to the 75% calculation. Another requirement for the no worse off clause is that there should be no break in membership when moving from your previous scheme to GEMS. Please refer to the contribution calculator for further guidance on the calculation of your employer subsidy.

Why am i suspended?

There are various reasons for suspending benefits, each with a different cause and impact on you. Suspension due to incomplete registration: This type of suspension is caused when insufficient supporting documentation was provided for the registration of the member or dependant. As the registration process is not complete, no benefits will be made available, nor will contributions be collected. Please provide GEMS with all the requested documents in order to complete the registration. Suspension due to contribution or claims debt: This type of suspension is caused by non-receipt of contributions or any member's share of claims. There are several reasons for not receiving a contribution, and it is in your interest to contact GEMS to resolve the matter. Please note that although benefits are not available during the period of suspension, contributions are still payable. You will not be entitled to a refund of contributions should benefits have been suspended, therefore always ensure that deductions are made from your monthly salary (or bank account, where applicable).

Where can I get all the information I need on the calculation of the employer subsidy and the employer subsidy rules?

To ensure that you have all the information on the employer subsidy policy, you should read the Determination from the Minister for the Public Service and Administration on Medical Assistance for the Public Service as well the Circular from the Department of Public Service and Administration (the DPSA) under reference1/6/23/P dated 29 September 2006. The Determination and Circular are available in your HR office and can also be accessed on the DPSA website at http://www.dpsa.gov.za/ Also refer to Circular 17/12/P of 9 March 2010 for the latest salary adjustments.

With effect from which date is GEMS implemented?

GEMS became operational on 1 January 2006. Public service employees started enrolling on GEMS and the first claims from new members were paid in mid January 2006.

If a member dies, will his registered dependents still be covered?

Yes, if the member has not had a break in membership and provided that the contributions are paid. The eldest dependant (if no spouse is registered as a dependent) will then be registered as the main member (adult dependent rates then apply). Normally the Estate is responsible for the monthly payments.

Must I give notice to GEMS in the event that I wish to terminate membership?

Yes, at least 1 (one) calendar month's written notice would be required. The member may terminate membership of the Scheme by giving one calendar month written notice, in line with the rules of the Scheme.

What role does my employer play in my relationship with GEMS?

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.

Can I register my dependants under my name on GEMS, even though I am covered by another scheme?

No person may belong to more than one medical scheme at the same time. You may thus not be registered on two schemes. Even if your dependants are not covered on your current scheme, you may not join GEMS with the purpose to obtain cover only for your dependants. This constitutes dual membership.

Is it compulsory for all public service employees on a medical scheme to move over to GEMS? If not, will they still receive the medical scheme subsidy?

Enrolment on GEMS is voluntary for public service employees who were appointed before 1 July 2006 and were principal members of open medical schemes in June 2006. Employees who were appointed with effect from 1 July 2006 as well as employees who were not principal members of open schemes in June 2006 will receive the employer subsidy on GEMS only.

Is it compulsory for new permanent appointments to join GEMS or can they join any medical scheme of choice and be subsidized?

New appointees with an appointment date of 1 July 2006 or later will only be subsidised on GEMS. They will not qualify for an employer subsidy if they join an open medical scheme.

Can contract workers join GEMS?

Contract employees whose term of appointment is at least 6 months may join GEMS. Note that some contract employees are remunerated by means of all-inclusive remuneration packages, i.e. basic salary and a cash amount calculated as 37% of basic salary. PERSAL will not generate an employer subsidy when such a contract worker joins GEMS since the subsidy is already built into the remuneration package.

Who qualifies as a dependent?

A dependent is: Husband, wife or partner involved with the main member in any same-sex or heterosexual union.; Ex-husband or ex-wife if required by a divorce settlement. Children (biological, adopted, step or foster); Parents, parents-in-law, step parents, step parents-in-law, grandparents and grandparents-in-law if they are factually dependent on the main member; Grandchildren and great-grandchildren if they are factually dependent on the main member. Siblings (brothers and sisters), half-siblings, step-siblings and in-law siblings if they are factually dependent on the main member; Nephews and nieces if they are factually dependent on the main member or of a member's spouse; A person, other than family, who is dependent on the main member for family care and support To be registered as a child dependant, a person must either be: under the age of 21; under the age of 28 and registered as a bona fide student at an educational institution recognised as such by the Board within South Africa or any other educational institution abroad; or totally dependent on the main member and who is deemed by the Board to be permanently disabled, irrespective of age. For most of the dependant categories outlined, an affidavit that proves factual dependency should be submitted with the application form. (Not older than three months.) An affidavit is a written declaration made under oath in front of someone legally authorised to administer an oath (for example, a Commissioner of oaths, or a police officer).

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