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MG25
MEMBER G UIDE

C HRO NIC MEDIC IN E

Supporting you every

step of the way
 Table of
Contents

1. The GEMS Chronic Medicine Management Programme 1

2. How to join the GEMS Chronic Medicine Management Programme 5
3. How to stretch your benefits and avoid co-payments 7
○ When and why would I run out of chronic benefits? 7
○ What are generic medicines, and how can I benefit from them? 8
○ Why are generic medicines cheaper than brand-name medicines? 8
○ What are therapeutic equivalents, and how does it benefit me? 9
○ What are co-payments, and how can I avoid or minimise them? 9
○ What is the GEMS formulary, and why should my doctor prescribe medicine
from the formulary if I register a PMB condition? 11
○ What is the DRP, and why should my pharmacist provide my chronic medicine
in line with the reference price on the DRP? 12
○ Who are the GEMS DSPs for chronic medicine, and why should I nominate a
pharmacy from the list of DSPs? 13
○ The GEMS Chronic Courier Pharmacy 13
○ GEMS Network Pharmacies 14
○ How can I keep track of my authorised chronic medicine using my MAC? 15
○ What if my doctor changes my medicine, or prescribes an additional medicine that is not
on my MAC? 16
4. Handy tips and facts for those already on the programme 18
○ Chronic medicine compliance 18
○ Prescription renewal 20
○ Care co-ordination 20
○ Lifestyle choices 20
○ Preventative screening 21
5. Walk-in Centres 24
6. Get in touch 25
 The GEMS Chronic
Medicine Management
Programme

Who qualifies for the programme?

All members or beneficiaries who have a chronic or to join the Chronic Medicine Management (CMM)
long-term condition such as high blood pressure Programme. You will need to register your chronic
that requires medicine on an ongoing basis, qualify condition with GEMS.

Why does it make sense to join?

If you have been diagnosed with a chronic condition you have available for acute medicines that you may
that is covered by GEMS under the GEMS Chronic need from time to time.
Medicine Management (CMM) Programme, but do
not register your condition on this programme, our The CMM Programme also gives you access to the
systems will automatically process your medicine GEMS Disease Management Programmes (DMPs)
claims for the condition as an ‘acute’ claim. This will with disease managers to help you and your doctor
deplete your acute medicine benefit which is meant manage your illness.
for day-to-day medicine claims such as antibiotics
or pain medication for short-term use. You may also In addition, for certain chronic conditions the
incur co-payments. programme will not only cover the medicine but
will cover consultations and other procedures or
Your chronic medicine benefit is a separate benefit, investigations to manage and monitor the condition.
which means that claiming for medicine for your This is referred to as a care plan.
registered chronic condition will not reduce the cover

GEMS Chronic Medicine Member Guide 2025 1

What chronic conditions are covered, and how?
It is important to remember that not all chronic conditions qualify to be registered on the CMM Programme.
There are two basic types of chronic conditions that are covered in terms of this programme:

Conditions covered in terms of Prescribed Additional (non-PMB) chronic conditions that

Minimum Benefits (referred to as ‘PMB are covered by GEMS under certain options
conditions’, in short)
These are usually chronic conditions that can be GEMS has approved a range of additional chronic
disabling and/or potentially life-threatening if not conditions for which members can enjoy cover,
treated, such as diabetes or high blood pressure. depending on the benefit option they are on.
All medical schemes must offer their members
treatment for these in terms of PMB requirements. Medicine for these conditions will be covered from
*For more information on mandatory chronic your chronic medicine benefit. Cover for these
benefits, please click here. Alternatively, go to conditions is also based on certain formularies
the Council for Medical Schemes (CMS) website and a reference price system, so you may incur
and scroll down to ‘Quick Access’ and clink onto co-payments even before your chronic medicine
‘Prescribed Minimum Benefits (PMBs).’ benefit is depleted. The good news is that there are
ways to stretch your cover and avoid or minimise
Registering a PMB condition also gives you access co-payments (see page 7).
to a care plan, with a range of services such as
doctor’s visits, blood tests and x-rays, to ensure Once this benefit is depleted, you will have to pay
that you receive sufficient benefits to proactively from your own pocket.
manage and monitor your PMB chronic condition.

Treatment for these conditions will first be funded

from your chronic medicine benefit. Once this
benefit is depleted, your condition will be covered
in terms of PMB. This means that although you will
continue to have cover for your PMB condition,
such cover will be according to predefined PMB
standards, including managed care protocols,
processes, and formularies. More about this is
covered in the next section.

For your chronic medicine to be covered from the chronic medicine benefit without any co-payments, it
needs to be –
• in the GEMS formulary (in the case of a PMB condition);
• priced within the Drug Reference Price (DRP); and
• supplied by your nominated GEMS DSP.

Read more about this on page 7.

Payment of medicine from the chronic benefit is governed by the GEMS Scheme Rules around waiting periods and the Scheme’s exclusions, available
benefits, and clinical guidelines, all of which may be updated periodically.

GEMS Chronic Medicine Member Guide 2025 2

* More about PMBs
The Medical Schemes Act provides for the diagnosis and treatment of a list of conditions known as Prescribed
Minimum Benefits, which include emergencies, Diagnosis and Treatment Pairs (DTPs), and a list of chronic
diseases included on the Chronic Disease List (CDL).

A DTP links a specific diagnosis to a treatment and broadly indicates how each of the PMB conditions should
be treated or managed in a hospital setting. Whilst DTPs are mostly hospital-based, there are some DTPs that
are for out-of-hospital management, for which treatment may include acute medicines.

The Chronic Disease List (CDL) specifies medication and treatment for 26 chronic conditions for which medical
schemes not only have to cover medication, but also doctors’ consultations and tests related to the condition.
Medical schemes may make use of protocols such as formularies and specific providers, also known as
Designated Service Providers (DSPs), to manage this benefit.

Check the table on the next page to see whether your chronic condition is covered on your option.

GEMS Chronic Medicine Member Guide 2025 3

Find your chronic condition
PMB conditions Additional (non-PMB) conditions
Tanzanite Beryl Ruby Emerald Emerald Onyx Tanzanite Beryl Ruby Emerald Emerald Onyx
One Value One Value

Addison’s Disease Erythematosus Anxiety

Asthma Glaucoma Attention deficit and hyperactivity disorder Depression (pays
Bipolar Mood Disorder Haemophilia above chronic medicine limits)
Bronchiectasis HIV/AIDS
Ruby Emerald Emerald Value Onyx
Cardiac Failure Hyperlipidaemia
Cardiomyopathy Hypertension Benign prostatic hyperplasia
Chronic Renal Disease Hypothyroidism Meniere’s disease Osteoarthritis
Coronary Artery Disease Multiple Sclerosis Psoriasis
COPD Parkinson’s Disease Thrombo-embolic disease*
Crohn’s Disease Rheumatoid Arthritis
Emerald Emerald Value Onyx
Diabetes Insipidus Schizophrenia
Diabetes Type 1 Systemic Lupus Acne Interstitial lung disease
Diabetes Type 2 Ulcerative Colitis Allergic rhinitis Menopause*
Dysrhythmias Alzheimer’s disease Myasthenia gravis
Epilepsy Ankylosing spondylitis Narcolepsy
Anorexia nervosa Neuropathies
#
Including (but not limited to), multi-infarct, sub- cortical Barrett’s oesophagus Obsessive compulsive
Bulimia nervosa disorder
vascular and alcohol.
Delusional disorder Osteopenia
*Chronic DTP PMB conditions are covered on all
Dementias# Osteoporosis
options in accordance with the Scheme formularies. Paget’s disease
Dermatitis
Eczema Post-traumatic stress
syndrome
Gastro-oesophageal
Stroke*
reflux disease
Systemic sclerosis
Generalised anxiety disorder
Thrombocytopenic purpura*
Gout
Tourette’s syndrome
Huntington’s disease
Valvular heart disease
Hypoparathyroidism
Zollinger-Ellison syndrome
* Hyperthyroidism*

What are the ‘terms and conditions’ of the

programme?
The Council for Medical Schemes (CMS) allows A great resource to better understand how this works
schemes to implement procedures and protocols to is the PMB FAQs section on the Council for Medical
limit what members may claim for chronic conditions. Schemes (CMS) website. More information is also
This enables medical schemes to offer their members available on the GEMS website. Alternatively, go to the
quality care for chronic conditions without jeopardizing GEMS website and click onto the ‘information icon’ and
their financial sustainability. This holds especially true scroll down to ‘Prescribed Minimum Benefits (PMBs).’
for PMB conditions, where cover can sometimes
mistakenly be interpreted as ‘open-ended’ or ‘unlimited’.

GEMS Chronic Medicine Member Guide 2025 4

 How to join the GEMS
Chronic Medicine
Management Programme

GEMS has streamlined the process of registering on this programme, so it’s easier to join
than ever before!

What do I need to do to register?

Before you start the process of registering on the CMM Programme –

Check that your chronic condition is covered by GEMS (see page 4).

Have a copy of a valid prescription available, detailing the doctor’s details (name and practice
number), the diagnosis or ICD-10 codes and the medicine details, such as name, strength,
dosage form and directions for use.

How to register and make updates on the GEMS

CMM Programme
To register or make updates on existing conditions, you do not even need to complete forms or email us any
documents (unless your condition requires more information, in which case we will let you know). You, your
doctor, or your pharmacist can register or make updates to existing conditions immediately*, telephonically!
Simply –

1. Call 0860 004 367 For script renewal purposes, you, If your doctor prefers to complete a
2. Press 4 for pre-authorisations your doctor or pharmacist can send physical application form, a chronic
3. Press the appropriate option for an email to chronicdsp@[Link]. medicine form can be downloaded
your language preference za to obtain authorisation for new from the GEMS website, under
4. Press 3 for chronic medicine chronic conditions. Forms. Bear in mind that the
enquiries turnaround time for a paper-based
application is five working days.
5. Press 1 to register for a chronic
medicine

TIP: This is the quickest method to register *The exception to this time frame is when the request must be referred for further clinical review,
and make updates. which can take up to seven working days.

GEMS Chronic Medicine Member Guide 2025 5

How will I know that I have been successfully
registered?
After processing your registration, the CMM team will call, chronic authorisation letter and Medicine Access
clinically review and determine the outcome of your Chart (MAC). You can read more about your MAC,
application for chronic medicine funding. You will and how to use it, on page 15.
receive an SMS indicating that the application has
been processed. You can look out for an email with a Once registered on the Programme make sure to
detailed letter on the outcome within 5 working days. email your chronic script to chronicdsp@[Link].

If there is still some information outstanding before we What if my registration was not
can finalise your registration, you will receive a letter approved?
indicating what we still need from you or your doctor.
Your doctor may contact the CMM Programme to
appeal a clinical decision or submit a clinical motiva-
Once your medicine is authorised, you will be enrolled on
tion for review, using the contact details above.
the CMM Programme, and you will receive a welcome

How do I nominate a pharmacy for my chronic

medicines?
Once you are registered on the CMM Programme, • the GEMS Chronic Courier Pharmacy; or
GEMS will contact you to help you select a Designated • a GEMS Retail Network Pharmacy.
Service Provider (DSP) from which your authorised
chronic medicine(s) will be obtained.
This can be from –

The benefits of using either of the above options for

your chronic medicine are that:
• You are less likely to incur non-DSP related co-payments.
• You benefit from negotiated rates to help your benefits
last longer.
• You can obtain enhanced quality of care.
• You are served with professionalism.
• Network Pharmacies have enhanced product knowledge
and are required to comply with GEMS requirements.
• You obtain cost-effective medicine.

In addition, the Courier Pharmacy delivers medicines to you for

free – at home or to any other preferred address.

Read more about the GEMS Chronic Courier Pharmacy and

Retail Network Pharmacies on page 13.

GEMS Chronic Medicine Member Guide 2025 6

 How to stretch your
benefits and avoid
co-payments

When and why would I run out of chronic benefits?

Depending on the chronic condition you have registered for, and how you use your benefit, you may at some
stage find that you have depleted your chronic medicine benefit and must now pay certain costs out of your
own pocket. This is why:

If you are registered with the Chronic Medicine Management Programme:

• for a PMB chronic condition, chronic medicines are first covered from your chronic medicine benefit.
When the benefit is depleted:
○ you will have access to further cover in terms of PMB (but with very specific guidelines - see page
2).
• for an additional (non-PMB) chronic condition, chronic medicines are first covered from your chronic
medicine benefit. When the benefit is depleted:
○ you will have to pay for further chronic medicine claims from your own pocket.

This is why it is important to understand how you can stretch your benefits and minimise co-payments. There
are several ways of doing so.

These include:
• Using generic or cost effective therapeutic equivalent medicines and the GEMS DSPs to provide your
medicine; and
• Asking your pharmacist for a generic within the GEMS DRP price range.

GEMS Chronic Medicine Member Guide 2025 7

What are generic medicines, and how can I benefit
from them?
Generic medicine (also called a generic substitute) Medicines for which there may be a generic alternative
is a product that is similar to the original product in are indicated with an X on your chronic Medicine
terms of active ingredients, strength, and form. In Access Chart (MAC). By using the generic alternatives,
South Africa, once pharmaceutical companies obtain you can get more value from your benefit limit, as the
approval from the South African Health Products benefit to cover your medication will last longer. This
Regulatory Authority (SAHPRA) to sell their newly is because generic medicines are between 20% and
developed medicines, they have patent protection 40% more cost-effective than original brand medicines.
that effectively lasts between 5 and 15 years. During
this time, no other company is allowed to manufacture Unfortunately, because generic medicines are cost
this specific medicine. effective compared to brand-name medicines, there is
a general misconception that they are not as good as
Once the patent period has expired, any other company the original brand-name medicines. This misconception
may produce the same medicine under a different carries a cost, as members who continue using brand-
commercial name, using the same formulation (active name medicines are spending far more on medicines
ingredients). The company may sell their product, than is necessary.
provided it has been registered with SAHPRA, and its
quality has been approved by the regulatory authority. Not all medicines have a generic equivalent, but your
South Africa is privileged to have some of the world’s pharmacist will advise on this.
leading generic manufacturers, producing quality,
affordable, and safe medicines.

Why are generic

medicines cheaper than
brand-name medicines?
The difference in price is due to up-front research
costs. Before a medicine is approved, the drug
company that developed the original product would
have spent large sums of money on research and
development. Once for sale on the market, this drug
company will attempt to recover these costs and
do their best to make a profit from their investment.

Generic medicines are cheaper, as the manufacturers

do not incur the associated costs for the long and
expensive process associated with research and
development. Generic drug companies can simply
copy the formula in terms of active ingredient, strength,
and form once the patent period has expired.

GEMS Chronic Medicine Member Guide 2025 8

What are therapeutic equivalents, and how does it
benefit me?
Therapeutic equivalents are different medicines that and your doctor more flexibility with regards to the
treat the same condition in a similar way and differ medicine available to you.
in price.
This only applies to certain groups of medicine and all
Previously the high-costing medicines were excluded medicines can be found in the Drug Reference Price
and only the more affordable items were funded in a (DRP) list. To access the DRP list go onto the GEMS
particular therapeutic group of medicines. website >>> click onto (Healthcare Providers >>>
Formulary lists). Alternatively, click here.
Now in some therapeutic group of medicines, you
will be able to access the high-costing medicine, that You can also call 0860 00 4367 or email chronicauths@
was previously excluded at a predetermined amount [Link].
called the Drug Reference Price (DRP). This gives you

What are co-payments, and how can I avoid or

minimise them?
A co-payment is that share of a chronic medicine following pages. Some are indicated on your chronic
claim that you must pay from your own pocket, usually Medicine Access Chart (MAC – see more about this
directly to the dispensing pharmacy. on page 15).

There are three different types of co-payments, The good news is that you can avoid, or at least
and you can incur more than one of these at a time. minimise, co-payments! This is how...
You can read more about these co-payments on the

There are three factors that will affect whether you incur co-payments on
your chronic medicine.

These are covered in greater detail from page 11 onwards but,

in short, they are:
1. If you are registered for a PMB condition, and whether the medicine your
doctor has prescribed is on the GEMS chronic medicine formulary.
2. Whether or not your medicine costs more than the GEMS maximum
price in our Drug Reference Price (DRP) for that medicine, for which
there is a generic or cost effective therapeutic equivalent available. This
would typically happen if you choose the original branded medicine,
rather than a less expensive generic alternative.
3. Whether or not you used the GEMS DSP (your nominated Retail Network
Pharmacy or the GEMS Courier Pharmacy) to obtain your chronic medicine.

A list of the GEMS Network Pharmacies is available on the GEMS website

(For Individuals > Designated Healthcare Providers).

GEMS Chronic Medicine Member Guide 2025 9

Before getting a prescription for new medicine from your doctor, confirm the following:

In the case of a PMB condition: Is the prescribed medicine on the GEMS

formulary?
TIP: Your doctor or pharmacist, or even you, can check the formulary on the GEMS website, email
chronicdsp@[Link] or call 0860 004 367.

YES NO

Is there a generic alternative or a cost-effective Is there an alternative in-formulary

therapeutic equivalent, and does its price fall medicine available?
within the GEMS Drug?
TIP: Discuss generic alternatives and cost-effective therapeutic TIP: Discuss potential alternatives on the GEMS formulary with
equivalents with your doctor and/or pharmacist. your doctor.

YES YES NO

NO Do I opt for the medicine You will always incur You will NOT incur an
within the DRP? an out-of-formulary out-of-formulary
co- payment for certain co-payment.
YES drugs/ conditions
NO
(indicated on your
chronic MAC with ‘+ OF’),
while for other drugs/
You will NOT incur any You will incur a DRP co- conditions (indicated on
DRP co-payment. payment (indicated on your chronic MAC with
your chronic MAC with ‘# OF’) you will incur this
an ‘X’). The co-payment co-payment only once
will be the difference you have used up your
between the price of annual limits.
the medicine you take
and the maximum price The co-payment will be
that GEMS will pay for 30% of the price of the
the medicine. medicine.

Am I using my nominated pharmacy to fill the

You will incur a non-DRP co-
prescription? NO
payment of 30% of the price of
the claimed medicine.
YES
TIP: To avoid this co-payment, obtain your
medicine from the pharmacy you nominated,
or from the GEMS chronic courier pharmacy
if you nominated the courier option.
You will NOT incur a non-DRP co-payment.

GEMS Chronic Medicine Member Guide 2025 10

What is the GEMS formulary, and why should my
doctor prescribe medicine from the formulary if I
register a PMB condition?
The GEMS chronic medicine formulary is a list of to find out which medicines are on the comprehensive
medicines that GEMS will pay for from your chronic chronic medicine formulary. Alternatively, you can call
medicine benefit if your PMB chronic condition is 0860 00 4367 or email chronicauths@[Link].
successfully registered with the Scheme. za or your doctor can call 0860 436 777 and follow
the voice prompts to reach the CMM department.
The formulary has been compiled by medical experts,
based on scientific literature and according to accepted However, if there is a sound medical reason to justify
treatment guidelines. These experts review the formulary the use of an out-of-formulary medicine to treatyour
regularly and update it when necessary to ensure that chronic condition, your doctor may submit a motivation
the most appropriate and cost-effective medicine is to GEMS. GEMS will assess this motivation to potentially
available to treat your chronic condition. waive the non-formulary co-payment.

By prescribing medicine from the formulary, Remember that even if formulary medicines are
your doctor will help you avoid out-of-formulary authorised and obtained from an allocated Network
co-payments. Pharmacy, they will incur a co-payment if they are
priced above the GEMS Drug Reference Price (DRP)
Visit the GEMS website (For Individuals > Formulary Lists) – which is what the next section covers.

GEMS Chronic Medicine Member Guide 2025 11

What is the DRP, and why should my pharmacist
provide my chronic medicine in line with the
reference price on the DRP?
The Drug Reference Price (DRP) List is a reference DRP reviews are conducted twice a year, and all changes
pricing system that GEMS uses to determine the are published on the GEMS website (for Individuals >
appropriate reimbursement rate for a group of medicines. Formulary Lists > Drug Reference Price (DRP).
The medicines are grouped according to generic or
TIP: Ask your pharmacist/doctor to supply medicine within the DRP
therapeutic similarity. The DRP does not restrict your reference price so that you can avoid a DRP co-payment. Your pharmacist
choice of which medicine to use (and in fact lists may substitute your prescribed medicine with a generic equivalent, as
allowed for in line with the regulations, which means there is no need to
the original, brand-name, generic and therapeutic have a new prescription issued by your doctor. You are simply required
alternatives), but it indicates the maximum price to give your pharmacist permission to provide the alternative equivalent
medicine. Changing between therapeutic equivalents will require a new
that GEMS will pay for a medicine. If you or the prescription and consultation with your doctor.
service provider chooses a medicine that costs more
than the reference price, you will have to pay the
difference.

GEMS Chronic Medicine Member Guide 2025 12

Who are the GEMS DSPs for
chronic medicine, and why
should I nominate a pharmacy
from the list of DSPs?
If you use a GEMS DSP to obtain your chronic medicine, you
will avoid incurring the 30% non-DSP co-payment (although,
depending on your other choices, you may still incur one or
more of the other co-payments shown above).

The GEMS DSPs for chronic medicine are –

• the GEMS Chronic Courier Pharmacy; and
• GEMS Retail Network Pharmacies.

The GEMS Chronic Courier Pharmacy

If you prefer having your chronic medicine delivered • You will receive an SMS with a unique tracking
to you, rather than collecting it from a designated number before the Courier Pharmacy delivers
Retail Network Pharmacy, the GEMS Chronic Courier your parcel, so that your package can always
Pharmacy is for you! be traced.
• If you have not supplied a cellphone number or
The GEMS Chronic Courier Pharmacy delivers – if the SMS is not successfully delivered to your
• free of charge; phone, a Courier Pharmacy consultant will call
you to give you the tracking number.
• on weekdays, between 08:00 and 17:00;
• You, or the person who receives the parcel,
• to a work, home, or holiday address, or to your
may have to produce identification and sign
doctor’s rooms if you have made a delivery
the delivery note when the Courier Pharmacy
arrangement with your doctor.
delivers the medicine.
• If you choose the Courier Pharmacy as your
Things to bear in mind
DSP for chronic medicine delivery, you will
• An authorised person older than 18 years is be allocated to the Courier Pharmacy for a
required to sign your medicine parcel. The minimum period of six months, in line with your
details of this person must be provided to the prescription cycle.
Courier Pharmacy before the delivery date.
• The details of the chronic medicine delivered to
• The delivery note included in the parcel will you are always kept confidential.
detail the address that GEMS has on file as the
delivery address. Ensure that GEMS always
has your current contact details on record.

GEMS Chronic Medicine Member Guide 2025 13

Other questions you may have about language, select option 3, and then select option 3
couriered medicines again. The delivery schedule is sent with every parcel
and should be used as a guide to determine when the
How do I pay co-payments? next parcel is due. You can update your details when
If there are co-payments for the medicines dispatched you call. In case of a delay, the Courier Pharmacy will
to you by the Courier Pharmacy, you can make payment contact you to make alternative delivery arrangements.
using direct deposit, credit card or debit order, EasyPay
or Pay@. The payment should be made directly to How safe is couriered medicine?
the Chronic Courier Pharmacy. The account details All medicine is wrapped in protective material to ensure
will be provided on the invoice dispatched with your that it is not damaged in transit. Medicine in fragile
medicines. Please use your Chronic Courier Pharmacy containers is placed in plastic containers marked
Profile number or GEMS membership number as with ‘valuable cargo’ stickers, to ensure careful and
your reference and email the proof of payment to safe handling.
chronicdsp@[Link], or fax it to 0861 004 367.
Parcels containing cold storage items, such as insulin,
How do I change my delivery address? are packaged, kept cool and dispatched only at 17:00
If you will not be available for a scheduled delivery to each day just before transportation. These parcels are
the address on record, or if you are going on holiday, packed securely, marked ‘refrigerated and fragile’ and
for example, inform the Courier Pharmacy at least sent with ice packs to maintain the correct storage
seven working days before the delivery date. To do conditions in transit. All efforts are taken to ensure the
this, please call 0860 004 367, select option 4, select medicine delivered to you is in a safe and integral state.

GEMS Network Pharmacies

GEMS offers you a choice of Retail Network Pharmacies However, any subsequent claims will attract a non-
near your home or your work, whichever is more DSP co-payment of 30%. You do not pay a non- DSP
convenient to you. To see a list of these pharmacies, co-payment if you use your nominated Network
please visit the GEMS website (For Individuals > Pharmacy, so it is in your best interest to get your
Designated Service Providers > Pharmacies), then authorised chronic medicines from there.
select your province and a pharmacy near you.
When should I collect my medicine?
Once you have chosen a pharmacy, you will be
GEMS allows you to collect your prescribed chronic
registered with that pharmacy and must obtain your
medicine from the pharmacy every 28-days. Should you
chronic medicine from it for a minimum period of six
collect your medicine too early (before the scheduled
months, in line with your prescription cycle.
day), your claim will not be paid. This is because GEMS
cares about your health and recommends that you
What if I get my chronic medicine do not keep more than one month’s supply of your
from a pharmacy other than the one, chronic medicine at home.
I have nominated?
TIP: To ensure that you are not collecting your prescription too early, ask
Your first claim from a pharmacy other than your your pharmacist when your next collection date will be. This will ensure
that your chronic medicine claims are paid, saving you time as well as
nominated Network Pharmacy will be paid in full. travelling costs, as you will avoid an unnecessary visit to the pharmacy.

GEMS Chronic Medicine Member Guide 2025 14

How can I keep track of my authorised chronic
medicine using my MAC?
Below is an example of a chronic Medicine Access pharmacy a prescription before your chronic medicine
Chart (MAC) that members who register on the CMM can be dispensed.
Programme will receive to confirm their chronic medicine
authorisation. Your chronic MAC shows your GEMS membership
number, beneficiary code and the medical condition
If your application to register on the CMM programme for which you are registered. Additional medicine
is successful, you will receive a letter with your own approved outside of your condition’s basket, or those
chronic MAC. With every update made to your chronic with special exceptions, will be listed individually on
conditions, or when a new medicine is authorised, the chart.
you will be sent a new MAC.
Your chronic MAC also gives you information on
Your chronic MAC tells you and your pharmacist the payment rules for each of the listed medicine(s)
what chronic condition(s) you are approved for, but authorised for you, which can help you avoid potential
it is not a prescription. You will still need to give your co-payments.

This indicates medicine for which a treatment

basket is available – see page 16 for more
The payment rules are summarised below. information about treatment baskets.

Chronic Medicine Management Tel No: 0860 004 367 MEDICINE ACCESS CHART

Payment of the treatment below is subject to available benefits and will be rejected once limits have been exceeded (if applicable).

Presentation of this card does not guarantee that the bearer of this card is a valid Beneficiary of the medical scheme.

Scheme: GOVERNMENT EMPLOYEES MEDICAL SCHEME # OF drug: co-payment will apply above limits Application Number:
*** Disease Authorisation: Disease Basket available GMS0921000028
Med Aid No: 001316624 Beneficiary
Member: xxx Code:  01 + OF drug: co-payment will always apply
Beneficiary: xxx EXG drug: payment will continue above limits
M: Macular Degeneration co-payment may apply
N drug: payment will NOT continue above limits
PMB drug: payment will continue above limits
PMB condition: payment may continue above limits
S: Specialised Drug co-payment may apply
X DRP drug: co-payment may apply

Approved Medicine or Condition From To Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

PMB + Entocord 3mg Aug 2021 Ongoing 30 30 30 30 30 30 30 30 30 30 30 30

PMB Methotrexate 2.5mg Aug 2021 Ongoing 20 20 20 20 20 20 20 20 20 20 20 20

PMB Crohn'S Disease Aug 2021 Ongoing *** *** *** *** ***

X N Asacol 500 mg Aug 2021 Ongoing 30 30 30 30 30 30 30 30 30 30 30 30

X N Buscopan 10mg Aug 2021 Ongoing 30 30 30 30 30 30 30 30 30 30 30 30

EXG Humira Pre-Filled Syringe 0.8ml 4 Aug 2021 Jul 2022 2 2 2 2 2 2 2 2 2 2 2 2

This column shows the payment rule that This column shows the name of the chronic condition
will apply for each medicine or condition. treatment basket or authorised medicine for which you
have been registered.

GEMS Chronic Medicine Member Guide 2025 15

 If your medicine is marked with: It means that ...
PMB GEMS will pay for this medicine throughout the year, even after your
chronic medicine benefit may become depleted. This means this medicine
is a Prescribed Minimum Benefit (PMB) for your authorised condition.
+ OF this medicine is not on the formulary, and you will have a co-payment
every time you get this medicine even if you still have benefits.
X DRP GEMS will pay for this medicine up to the maximum reference price in
the Drug Reference Price List (DRP).
EXG This medicine is approved for payment on the ex-gratia benefit and
is paid from the date it was approved as ex gratia, to the end date
indicated on the MAC.
N Once your chronic benefit for the year is depleted, GEMS will no longer
pay for this medicine.

More than one type of payment rule and medicine co-payment can apply to a single medicine.

What if my doctor changes my medicine, or

prescribes an additional medicine that is not
on my MAC?
You can add new medicine quickly and easily at your pre-approved medicines for a specific condition. This
pharmacy with a new prescription, without having to means that if your doctor prescribes a new medicine
contact the GEMS CMM department. for your chronic condition that is within the basket, it
will already be approved for your use without the need
This is because GEMS registers your chronic condition, to update the authorisation. Your treatment basket is
rather than approves specific medicines. Many indicated on your MAC (see page 15).
conditions have a ‘treatment basket,’ which is a list of

The only time it will be necessary to

contact us about the changes to your
chronic medicine is if:
• you are diagnosed with a new condition;
• the medicine you are prescribed for a
PMB condition is not on the formulary or
in the basket for your medical condition,
or
• you are requesting a higher-dosage
medicine than what is listed in the basket
for your medical condition.

GEMS Chronic Medicine Member Guide 2025 16

If your medicine is declined
If your medicine is declined, it means your medicine is not part of the defined basket of medicines for that
condition or your chronic medicine benefit (if not PMB) has been exceeded for the year.

You can:
• choose to pay for the medicine from your acute medicine benefit or from your own pocket,
• discuss the reasons for the decline with your doctor so that, if possible, they can change to an
alternative medicine within the basket, or
• ask your doctor to call 0860 436 777, or email chronicdsp@[Link], or fax to 086 100 4367
to provide clinical motivation for the medicines that have been declined to be paid from your chronic
medicine benefit.

If you use the GEMS Chronic Courier Pharmacy

Remember to email your new prescription to chronicdsp@[Link], fax it to 0861 004 367 or post the
original to GEMS at Private Bag X782, CPT, 8000, to arrange for your newly authorised chronic medicines.
TIP: Always email your new prescription to chronicdsp@[Link].

GEMS Chronic Medicine Member Guide 2025 17

 Handy tips and facts
for those already on
the programme

What should I know about

managing my chronic condition?
For the best possible health outcomes while on the programme, you
need to manage your chronic condition in the following respects:

• Chronic medicine compliance

• Timeous prescription renewal
• Care co-ordination
• Regular screening tests
• Lifestyle choices

Contact our knowledgeable and readily available team

of disease managers when in doubt.

Chronic medicine compliance

To best control your chronic illness, take your medicine regularly and exactly as your doctor has instructed.
This will help prevent your chronic condition from worsening and help prevent complications.

Take the correct dosage as prescribed by your doctor and indicated on your medicine labels.
Do not change your dose because you feel better or because you think you need more, or less,
medicine. Change the dose only if your doctor tells you to do so – this is especially important
with chronic medicine, as it prevents you from becoming sicker or developing other, or more
serious illnesses.

Take your medicine at the correct intervals as prescribed by your doctor; for example,
once, twice or three times a day. Make sure you understand exactly what these intervals mean
and adhere to them. Twice a day usually means every 12 hours – or morning and night. It does
not mean one tablet early in the morning and a second at lunchtime. If you are not sure what
the dosing intervals mean, ask your pharmacist.

GEMS Chronic Medicine Member Guide 2025 18

 Take it at the correct time. Should your doctor specify exact time(s) make sure to adhere to
the specification to ensure that your medicine works effectively.

Follow special instructions about food. Should your doctor or pharmacist give instructions
on when to take your medicine in relation to food, adhere to the instructions. If you are to take
your medicine before or after food, ask your pharmacist how long before or after food.

Most important of all, take your medicine on an ongoing basis. Chronic medicine is used
to treat chronic conditions. Your condition will not get better on its own. You need to take your
medicine for as long as your doctor says – usually for the rest of your life. Do not stop taking
your medicine because you feel better, or because a friend suggests you stop.

Although most members begin to feel well when taking If there is no record of claims for your chronic med-
chronic medicine, it does not mean that the illness is icines for three or more consecutive months, GEMS
cured. It only means that it is being controlled by the will contact you via telephone, SMS, or email to
medicine, so carry on taking your medicine to keep remind you of the importance of taking your chronic
feeling well. medication regularly.

If you are not able to take your medicine because of If you are no longer using your chronic medicines,
side effects or because it does not fit in with your daily please first discuss this with your doctor. The chronic
work or life schedule, discuss this with your doctor. authorisation department may then be contacted on
Do not stop taking your medicine without discussing 0860 004 367 (members), 0860 436 777 (providers),
it with your doctor. or an email may be sent to chronicdsp@[Link].
za to request that the authorisation be deactivated.
If you do not take your medicine as you should, or if
you skip doses or stop taking it, your chronic condition Another reason for non-compliance is often that
may no longer be controlled. Your symptoms may members do not visit their doctor for a renewal of
worsen, or you may even need to be hospitalised. their script, which is what the next section is all about.

GEMS Chronic Medicine Member Guide 2025 19

 Prescription renewal

Never interrupt your chronic medicine treatment. Make Certain medicines may not be prescribed on a repeatable
sure your prescriptions are always up to date by asking prescription, for example, high schedule medicines
your doctor for a new, repeatable prescription before such as S6, which require strict monitoring and control.
your current prescription expires. Your doctor will have to prescribe a maximum of one
month’s supply of this medicine for as long as it must
Your nominated pharmacy needs a valid and original be taken. Your pharmacist will require the original S6
doctor’s prescription to dispense your chronic medicine. prescription. Your doctor and pharmacist can help you
This is a legal requirement for scheduled medicines identify which of your prescribed medicines you need
and medicines for long-term (chronic) use. According to comply with this legislative requirement.
to legislation, you may not have more repeats than the
number specified by your doctor on your prescription, Your pharmacy will usually remind you to get a new
effective from the date of the prescription. A schedule prescription before your old one expires. GEMS will
6 (S6) prescription cannot be repeated at all, and a also remind you by sending you an SMS.
new prescription must be issued for each month the
medicine is required.

What to do with your new prescription

If you are using the GEMS Chronic Courier Pharmacy, email your new prescription to chronicdsp@
[Link], fax it to 0861 004 367 or post the original to GEMS on Private Bag X782, CPT,
8000 to arrange for your newly authorised chronic medicines.

If you are using a GEMS Retail Network Pharmacy, email your prescription to, chronicdsp@
[Link] or fax it to 0861 004 367, and hand the original prescription to your pharmacy.

Care co-ordination

To manage your chronic condition better, GEMS All members on Tanzanite One, Beryl and Emerald
recommends that you use one doctor, whenever Value need to obtain their prescriptions from a doctor
possible, to look after all your healthcare needs. You on the GEMS network.
can contact GEMS on 086 000 4367 to nominate this
doctor or email enquiries@[Link].

Lifestyle choices

Remember that a healthy lifestyle can have a positive chronic condition by making lifestyle changes such
effect on some chronic conditions such as high blood as incorporating appropriate exercise, eating healthily,
pressure, high cholesterol, and diabetes. Even if you sleeping well, and more. Speak to your doctor about
have to use chronic medicine for the rest of your life, potential ways of improving your general health.
you may be able to slow down the progression of your

GEMS Chronic Medicine Member Guide 2025 20

 Preventative screening

Screening tests are extremely important to ensure that Ask your pharmacist for the qualifying criteria for
medical conditions are detected early. Preventative the screening and preventative care tests funded by
care services such as flu vaccines, HPV vaccines, GEMS and use these services, because they can help
pneumococcal vaccines, and all other vaccines, as identify potential additional chronic conditions before
well as screening services such as cholesterol and they worsen. As GEMS will pay for these services
glucose screening, blood pressure monitoring, HIV from the preventative care and screening benefit, your
tests with pre- and post-test counselling, peak- flow day-to-day benefits will not be affected!
measurement, pregnancy screening and urine analysis,
are available at our Network Pharmacies.

What if I want to
register an additional
chronic condition?
If you are already registered on the CMM
Programme, and are diagnosed with an additional
chronic condition, you will need to check whether
your condition is covered by GEMS (refer to the
tables on page 4).

If your chronic condition is covered on your

option, simply call the GEMS chronic medicine
authorisation department for assistance. As a
member you may call 0860 004 367, or your
pharmacist or doctor can call 0860 436 777
to register this new condition on your behalf.

Please have all the required information available

before making the call, such as the prescribing
doctor’s practice number, the diagnosis and
diagnosis code, name of medicine, strength,
and the required dosage.

There are exceptions where the request may

have to be referred for further clinical review,
which can take up to 7 working days.

GEMS Chronic Medicine Member Guide 2025 21

How can I arrange for advance supplies?
Your health is important to GEMS, and we would not • All travel documents if using other modes of
like you to travel without your chronic medication. If transport while travelling.
you are planning to travel outside South Africa, you • A new prescription if your current prescription
may therefore apply for an advance supply of your expires during your time away.
chronic medicine (minimum one month’s medicine;
• Employment contract if travelling abroad for
maximum three months’ medicine).
work.
• Details of the date on which you will collect the
To apply, please complete an Acknowledgement of
medicine from your nominated pharmacy, or
Debt form (which you can find on our website, www.
the date on which you would like the GEMS
[Link], under Forms, or by calling us on 0860
Chronic Courier Pharmacy to deliver.
004 367 to request a copy) for each beneficiary and
email it to enquiries@[Link], or fax to 0861
004 367. GEMS will notify you if your advanced medicine supply
request has been approved or provide reasons if it
Attach the following documents to the request: has been declined.

• Flight itinerary or a letter confirming the

departure and return dates, or a travel plan if
you are travelling by road.

GEMS Chronic Medicine Member Guide 2025 22

What if I want to change my nominated Network
Pharmacy?
You can nominate a different network pharmacy or change to a Courier Pharmacy once the initial six-month
period has lapsed. To do so, call GEMS on 0860 004 367, select option 4, select your language, select option
3 and then select option 2, or email chronicdsp@[Link].

You may nominate another Network Pharmacy before the six-month period has elapsed
only if:
• You have changed employers, or your employment address;
• You have changed your residential address;
• Your preferred pharmacy is no longer part of the GEMS network; or
• You receive poor service or are unhappy with your current nominated Network Pharmacy.

What should I do about oversupplied medicines?

If you have more chronic medicine than you need at the end of the month, do the following:
• Check that you are taking your medicines exactly as your doctor instructed – at the correct dose,
quantity, and time intervals.
• Set reminders to take your medicine at a preferred time. Do not skip a day.

If you still have surplus medications:

• and you use the GEMS Courier Pharmacy to deliver
○ Inform us seven working days before your next scheduled delivery date (which you can see on
the delivery schedule that accompanies your medicine) that you would like to postpone or cancel
the next delivery. To do so, visit the GEMS website >>> click onto (For Individuals >>> Forms >>>
Chronic Medicine Application Form) or alternatively, click here. Print, complete and email GEMS the
‘Chronic medicine delivery amendment’ form or call 0860 00 4367.
• and you collect your medicine from a nominated Network Pharmacy
○ Speak to your pharmacist for guidance on how to use, or dispose of, the surplus chronic medicine.

GEMS Chronic Medicine Member Guide 2025 23

 Walk-in Centres

Province Street Address

EASTERN CAPE

East London Gillwell Shopping Centre, Shop LG36, Cnr Gillwell Road and Fleet Street

Mthatha Savoy Complex, Units 11 and 12A, Nelson Mandela Drive

FREE STATE

Bloemfontein Bloem Plaza, Shop 124, Charlotte Maxeke Street

Welkom Gold Fields Mall, Shop 51A, Cnr Strateway and Buiten Street

GAUTENG
Traduna House, 118 Jorrisen Street, Ground Floor, Cnr Jorrisen and Civic
Braamfontein
Boulevard (opposite Civic Centre)

Pretoria - Arcadia Sancardia Building, Shop 51, Cnr Stanza Bopape and Steve Biko Streets, Arcadia

LIMPOPO

Polokwane Shop 1, 52 Market Street

Thohoyandou Unit G3, Metropolitan Centre

MPUMALANGA

Mbombela (Nelspruit) Shop No 18, Nedbank Centre, 30 Brown Street, Nelspruit CBD

Safeways Crescent Centre, Shop S67, Cnr President and Swartbos streets, Die
eMalahleni (Witbank)
Heuwel
NORTH WEST

Klerksdorp City Mall, Shop 101, Cnr OR Tambo and President Street, Klerksdorp CBD

Mmabatho Megacity, Shopping Centre, Shop 39, Cnr Sekame and James Moraka
Mafikeng
streets, Mmabatho
NORTHERN CAPE

Kimberley New Park Centre, Shop 14, Bultfontein Wayand Lawson Street

Upington 61A Market Street

KWAZULU-NATAL

Durban The Berea Centre, Shop G18, Entrance 1, 249 Berea Road, Berea

Pietermaritzburg Maritzburg Arch, 39/45 Chief Albert Luthuli Street, Pietermaritzburg

WESTERN CAPE

Worcester Q Square Shopping Centre, Office 5, 72 High Street, Worcester Central

Cape Town Constitution House, 124 Adderley Street

GEMS Chronic Medicine Member Guide 2025 24

 Get in touch Like, Follow and Share

General Enquiries

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Disclaimer
Every effort has been made to ensure that all information provided to you is factual and accurate. However, in the event of a dispute, the Scheme Rules shall apply. You can view the Scheme Rules on our website at [Link].
za. The information provided on this correspondence is for information purposes only and cannot replace medical advice from your professional healthcare provider. We are committed to protecting your personal data. Your right to
privacy and security is very important to us. The Government Employees Medical Scheme (GEMS) and its contracted Service Provider Network (SPN) treat personal information as private and confidential. We collect personal
information for the purposes set out in the Scheme’s Registered Rules or otherwise communicated to you and we use your information for a number of different purposes, for example to provide our services to members and others
and to meet our legal and regulatory obligations. For more detailed information on how and why we use your information, including the rights in relation to your personal data, and our legal grounds for using it, please view the GEMS
Protection of Personal Information Policy and Promotion of Access to Information Manual on our website.