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Disease Management Programmes

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:

CHRONIC MEDICINE PROGRAMME

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 Medicine DSP), be it the Courier Pharmacy or the GEMS Network Pharmacy, 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 chronicauths@gems.gov.za. Your doctor can also contact the Chronic medinice DSP on 0860 00 4367. 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?

  1. Fax the handwritten, repeatable prescription from your doctor for the medicines listed on the Medicine Access Card to 0860 00 4367
    Remember to provide your membership number and contact details together with the handwritten repeatable prescription form your doctor.
  2. If you chose the Courier Pharmacy, they will contact you to finalise the date of delivery and the delivery address. 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 Courier Pharmacy know at least one week before your next delivery date.

You will pay extra if you do not use the Courier Pharamcy or your allocated Chronic Network Pharmacy

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 medication 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 medication 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. 

HIV/AIDS MANAGEMENT PROGRAMME

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?

The 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 telephone, fax and private mailbag facilities. If you or your dependants are HIV positive and decide to join the Programme, special care is taken to maintain your confidentiality.

What benefits are available?

If you register on the HIV/AIDS DMP, you will have access to the following benefits:

  1. Medicine to treat HIV/AIDS (antiretroviral therapy)
  2. Medicine to treat and prevent opportunistic infections related to HIV/AIDS, including multi-vitamins where appropriate
  3. Pathology tests
  4. Ongoing emotional support through a Nurse Line (phone service)
  5. Regular monitoring of your condition to ensure that you start treatment at the right time and that it is effective
  6. Clinical support and guidelines for treating doctors
  7. Help in finding a registered counsellor in your area
  8. Treatment to prevent the transmission of the virus from the mother to the child (including treatment for the baby)
  9. Treatment to prevent the transmission of HIV from accidental exposure to infected bodily fluids (sexual assualt, needle stick injury)
  10. Access to a specially trained medical team who will review your detials and consult with your doctor to ensure that you receive the most appropriate treatment for your condition.
  11. Reminders for you and your doctor to do regular check-ups and tests to monitor the state of your health and update your treatment where necessary.

Please call 0860 436 736 if you have had accidental exposure to HIV so that appropriate treatment, called post-exposure prophylaxis, can be arranged.

How do you register on the HIV/AIDS DMP?

  1. If you do not know your HIV status, ask your doctor or clinic to test you. GEMS will pay for this test and your doctor will be informed of the results.
  2. If you are HIV positive, call 0860 436 736 and ask for an application form.
  3. Your doctor will examine you and complete the form. GEMS will pay your doctor for completing the form.
  4. Fax your completed form to the confidential toll free fax number 0800 436 7329.
  5. We will contact you to discuss the outcome of your application.

How do you get your HIV/AIDS medicine?

The HIV/AIDS DMP registers, manages and cares for members while the Chronic Network Pharmacies and the Courier Pharamcy provide 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.

Whether you use the Chronic Network Pharmacy or your allocated Network Pharmacy, discussions about your medicine are confidential. If you choose the Courier Pharmacy, 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 medicine 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.

ONCOLOGY (CANCER) MANAGEMENT PROGRAMME

If you or a member of your family is diagnosed with cancer, it is important to register on the Oncology Management Programme as soon as possible as all oncology treatment requires pre-authorisation and case management.

How to register on the Oncology Management Programme:

Please make sure that your doctor informs the Oncology Management team of any change in your treatment, as your authorisation 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.

You can contact the Oncology Management team on 0860 00 4367.

You need pre-authorisation

You will need pre-authorisation for any hospitalisation, specialised radiology (for example, MRI scans, CT scans and angiography), stoma requirements or private nursing or hospice services. 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. In the case of an emergency, you need to get pre-authorisation on the first working day after the incident. If you do not get pre-authorisation, you may have to pay a penalty of R1 000 out of your own pocket.

You would also need pre-authorisation to see your GP on the Sapphire and Beryl Network after the first five consultations.

OPTOMETRY MANAGEMENT PROGRAMME

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 on the mini guide(available at www.gems.gov.za) 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'.

DENTAL MANAGEMENT PROGRAMME

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.

MATERNITY PROGRAMME

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

You can call us on 0860 00 4367to obtain a copy of the form.

Please fax the completed enrolment form to 0861 00 4367, email it to enquiries@gems.gov.za or post it to the GEMS Maternity Programme, Private Bag X782, Cape Town, 8000.

HOSPITAL MANAGEMENT

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?

Please note



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