GEMS offers its members specific care programmes to help manage various chronic diseases and conditions.
The benefits of being on a disease management programme include:
Medicine Management
Medicine prescribed by your doctor to relieve symptoms of a temporary illness or condition is called acute medicine and will be paid from the acute medicines benefit. However, not all medicines are paid in full. Always check with your doctor to see if the most cost effective medicine is prescribed according to the Medicine Price List (MPL) and the formulary list of medicines so that you do not have to pay anything extra from your own pocket. These extra payments are referred to as co-payments or deductibles. Some medicines are completely excluded from payment, either because of the lack of clinical evidence or they are not regarded as cost-effective.
What is chronic medicine?
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.
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?
Can you 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 [email protected]. 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?
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 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.
GEMS has an effective HIV/AIDS Disease Management Programme (DMP) for its members. If you or one of your dependants is living with HIV/AIDS, registering on the HIV/AIDS DMP can give you the support you need to lead a healthy and productive life.
Will your information be kept confidential?
f you or your dependants are HIV positive and decide to join the programme, special care is taken to maintain your confidentiality. This programme is managed by a team of healthcare professionals separately from other Scheme programmes and the employer. The HIV/AIDS DMP has its own confidential contact channels, which are:
What benefits are available?
If you register on the HIV/AIDS DMP, you will have access to the following benefits:
How do you register on the HIV/AIDS DMP?
How do you get your HIV/AIDS medicine?
The HIV/AIDS DMP registers, manages and cares for members while the Chronic DSP provides all Chronic medicine (including HIV medicine) to members. If you get your anti-retrovirals (ARVs or medicine to treat HIV) from any other pharmacy, you will have to pay 30% of the cost of medicine and dispensing fees.
When you use the Chronic DSP, discussions about your medicine are confidential and your medicine is delivered to your chosen address or nearest post office without anyone seeing what is inside. If you need medicine for other chronic conditions (for example, high blood pressure), it can be delivered together with your HIV medicine.
The Chronic DSP will also remind you to get a new repeat prescription 21 days before your current prescription is due to expire. All prescriptions expire after six months according to the law.
Click on the links below to access the HIV Disease Management Programme (DMP) brochures:
HIV counselling and testing (HCT)
If you or one of your registered beneficiaries are diagnosed with cancer, it is important to register on the oncology management programme as soon as possible. All oncology treatment requires pre-authorisation and case management.
Once the oncology management team has received your treatment plan from your doctor, your details, disease information and proposed treatment will be captured. Your treatment plan is reviewed and, if necessary, a member of the clinical team will contact your doctor to discuss more appropriate or cost-effective treatment alternatives.
After the treatment plan has been assessed and approved, an authorisation will be sent to your treating doctor. You will also be sent an authorisation letter. The letter will show the treatment authorised, the approved quantities and how long the authorisation is valid for.
Please make sure that your doctor advises the oncology management team of any change in your treatment, as your authorisation will need to be re-assessed and updated. If you fail to do so, your claims may be rejected or paid from the incorrect benefit as there will not be a matching oncology authorisation.
Please note:
You will need pre-authorisation for any hospitalisation, specialised radiology (e.g. MRI scans, CT scans, angiography), stoma requirements or private nursing or hospice services.
How to register on the Oncology Management Programme:
On diagnosis, your treating doctor should fax a copy of your treatment plan and a copy of the histology which confirms the cancer to 0861 00 4367 or email [email protected]. An oncology case manager will then take the process forward.
Once the Oncology Management team has received the treatment plan from your doctor, we will record your details, disease information and proposed treatment.
Your treatment plan will be reviewed, and if necessary, a member of the clinical team will contact your doctor to discuss more appropriate treatment or cost effective treatment alternatives. .
After the treatment plan has been assessed and approved, authorization will be sent to your treating doctor. You will also receive an authorization letter. The letter will show the treatment that GEMS has authorized, the approved quantities and how long the authorization is valid for.
After the treatment plan has been assessed and approved, authorization will be sent to your treating doctor. You will also receive an authorization letter. The letter will show the treatment that GEMS has authorized, the approved quantities and how long the authorization is valid for.
Please make sure your doctor informs the Oncology Management team of any change in your treatment, as your authorization will need to be re-assessed and updated. If your doctor does not inform the Oncology Management team about a change in your treatment, GEMS may reject your claims or pay them from an incorrect benefit.
Reasons for not funding treatment:
When registering on the oncology management programme, the clinical pre-authorisation team reviews the treatment proposed by your doctor and compares it to what is often referred to as the "standard of care". Such standard of care refers to what most doctors in South Africa would consider prescribing for a given cancer at a certain level of its growth and/or spread. The clinical managers also assess whether there are adequate funds based on your options' benefits limits, as well as how much money may have already been used during the course of the year.
There are various reasons that all or some of the treatment schedule that is being requested by your doctor may not be supported for purposes of payment.
Common reasons include the following:.
If you and your doctor follow the standard pre-authorisation process, you will always be informed whether the treatment planned by your doctor will be funded in your personal situation.
To assist you in your planning, we refer you to some of the common conditions and drugs where funding is limited on the basis that either cheaper treatments that are likely to be equally beneficial are available, or that the potential toxicity and cost of the drug cannot be justified in light of only very small expected clinical benefits associated with the treatment.
This approach ensures that there will be enough money to pay for effective treatments, where and if needed. Please note that other treatments not listed here may also not be reimbursed for reasons listed above.
View a summary of the most common Oncology treatments where funding is limited. Policies not listed here are available on request. If your treating doctor requires further information they may contact the Oncology Management team on 0860 00 4367 or via email at [email protected]
The optometry management programme provides you with clinically essential optometry benefits. This means that GEMS only covers expenses for optometry that are necessary for your health and your sight.
What we do not cover:
When you read the benefit schedule you will notice that there is a limit for your family, as well as a sub-limit for each beneficiary (members or dependants registered on the Scheme). This means that each beneficiary can claim only up to the maximum of the sub-limit, and the total that the family can claim for is limited to the 'family limit'.
GEMS has designed the dental benefit to ensure that members have access to cost-effective, quality dental healthcare. It is important for you to have regular dental check-ups.
What if you need dental treatment under general anaesthetic?
You need pre-authorisation for all procedures that require general anaesthetic or conscious sedation. If you are older than eight years, your treating dentist or dental specialist must give us the medical reason as to why general anaesthetic or conscious sedation is required for the dental treatment.
Please ensure you contact us to get pre-authorisation for hospitalisation at least 48 hours before treatment, unless it is an emergency.
Pre-authorisation means that you must get the Scheme's permission to use certain medicine or undergo a certain procedure at least 48 hours before it happens. If you do not do this, you will have to pay a penalty of R1 000 out of your own pocket.
Pregnant members and dependants of GEMS have access to the Maternity Programme. The programme is specifically designed to give you support, education and advice through all stages of your pregnancy, the confinement and postnatal (after birth) period.
To access your maternity benefits, pregnant members or dependants must register on the Programme as soon as their pregnancy is confirmed.
The Maternity Programme is headed by experienced, registered nursing sisters with additional qualifications in midwifery. These case managers will help you to register on the Maternity Programme and you can contact them on 0860 00 4367 for advice and information.
Other advantages of joining the Maternity Programme are:
Registering on the Programme
Click here to download the enrolment form that you need to complete. You can also call us on 0860 00 4367 to obtain a copy of the form.
Please fax the completed enrolment form to 0861 00 4367, email it to [email protected] or post it to the GEMS Maternity Programme, Private Bag X782, Cape Town, 8000.
The Hospital Management Programme ensures that you receive appropriate, quality healthcare while you are in hospital. The pre-authorisation process ensures that the planned procedure is both necessary and appropriate before you are admitted to hospital.
Get your pre-authorisation number first
You can apply for a hospital pre-authorisation number from GEMS by calling us on 0860 00 4367. You must get a pre-authorisation number in the following cases:
Pre-authorisation means that you must get the Scheme's permission to use certain medicine or undergo a certain procedure at least 48 hours before it happens. If you do not do this, you will have to pay a penalty of R1 000 out of your own pocket.
There are some admissions to hospital where we will not agree to pay for a drug or procedure. An example is when we believe that the drug or procedure is a new technology and that long-term results and positive outcomes have not been demonstrated by research. These cases will be discussed with you before is done or a drug is used or prescribed. GEMS might ask your provider for additional information and motivation in some instances but may still not agree to pay for the drug or procedure.
Please discuss all your treatment options with the treating doctor and make informed decisions regarding your and your loved ones' healthcare before you receive any treatment, drugs or undergo any procedure.
When must you apply for a pre-authorisation number?
Please let us know at least 48 hours before hospitalisation or procedure.
What happens in the case of an emergency if you cannot apply for a pre-authorisation number.
If you need to receive emergency treatment or be admitted to hospital over a weekend, public holiday or at night, you or a family member must call and obtain authorisation on the first working day after the incident.
What happens if you do not apply for a pre-authorisation number?
If you do not get a pre-authorisation number for a planned event or authorisation on the first working day after an emergency event, you will have to pay a penalty of R1 000.
What information must you have when you apply for a pre-authorisation number?
Only procedures that are covered in terms of the Scheme Rules will be paid for.
Please note
If your doctor or hospital obtains the pre-authorisation for you, the doctor and the hospital will receive the Scheme's official notice. It is very important that you get a copy and study the terms and conditions.
How to avoid being over serviced when admitted to hospital:
0860 00 4367 (Call Centre) [email protected] More Contacts >
