Chronic Medicine Management

What is chronic medicine?

  • Medicine for potentially life-threatening illnesses, like diabetes
  • Medicine used on an ongoing basis to treat disabling chronic illnesses that have a negative effect on your health and quality of life
  • Very expensive, short-term medicine (usually prescribed for more than three months) that will prevent other complications, such as hospitalisation

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 list of medicines so that you do not need to pay out of your own pocket.

Chronic medicine repeat prescriptions

Please ensure that you get a chronic medicine repeat prescription every six months. The Scheme's chronic designated service provider (Chronic DSP) will send you an SMS to remind you to renew your prescription before it expires.

How do I apply for chronic medicine?

  • Call GEMS on 0860 00 4367 and ask for a chronic medicine application form or download one here
  • 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, but you must send us a new prescription every six months. Even if there is a change to your chronic medicine, we will only need the new prescription, not a new application form.
  • 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 and repeatable doctor's prescription to 0861 00 4367 or via email to chronicdsp@gems.gov.za
  • We will review your application and check 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 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.

Can I appeal a medicine authorisation?

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 chronicauths@gems.gov.za. Your doctor can also contact the Chronic authorisation department 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.

How do you obtain your authorised chronic medicine?

  • Fax the handwritten, repeatable prescription from your doctor for the medicines listed on the Medicine Access Card to the Chronic DSP on 0861 00 4367 or via email to chronicdsp@gems.gov.za 
  • Remember to provide your membership number and contact details together with the handwritten repeatable prescription from your doctor
  • The Chronic DSP will contact you to discuss how you would like to obtain your medicine. They will ensure that you are allocated to a pharmacy of your choice or to the GEMS Courier Phamarcy. They will 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 let the Chronic DSP know at least one week before the next collection or delivery date.

You will pay extra if you do not use the Chronic DSP

If you prefer to get your approved chronic medicine from a pharmacy or dispensing doctor of your choice who is not the Scheme's Chronic DSP, you will have to pay 30% of the cost of the medicine and the dispensing fee. You must pay the 30% directly to the pharmacy or doctor.

You will pay extra if you use medicine that is not on the GEMS formulary (medicine list)

If your doctor prescribes medicine that is not on the GEMS medicine list (referred to as the formulary), you will also have to pay part of the medicine cost even if it is authorised on the chronic benefit. A co-payment of 30% will apply. You must pay the amount directly to the pharmacy or doctor. The formulary is checked continuously and medical experts update it to ensure that it is consistent with the latest treatment guidelines.

Does GEMS pay for all chronic medicine prescribed by doctors?

GEMS 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 the requested medicine is not in line with the clinical guidelines.

Only diseases listed on the Chronic Disease List (CDL), as it appears on 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 the acute medicine benefit. Please refer to the word list for an explanation of the Chronic Disease List and the Additional Chronic Disease List.