Please contact our Call Centre on 0860 00 4367 or email enquiries@gems.gov.za if you require any further assistance with the completion of your application form.

1. Read the application guide carefully, as it contains important information that will assist you in completing the application form correctly.

2. Complete the application form overleaf and ensure that you have included all relevant documentation as well as your signature where required.

3. Submit the form and supplementary documentation to GEMS in any of the following manners:

• Fax:0861004367• Email:enquiries@gems.gov.za• Regionaloffices:Refertotheapplicationguideformoredetail• Postaladdress:GEMS,PrivateBagX782,CapeTown8000

4.Ifyourapplicationissuccessful,GEMSwillpostawelcomepacktoyouwithin7daysofreceiptofyourapplication.

5. Your application will be delayed if you do not provide GEMS with all the required documentation.

6.Ifyourapplicationcouldnotbeprocessed,GEMSwillcontactyouwithin5daysofreceiptofyourapplication.

Quick Guide to Becominga Member of GEMS

SECtion A: MEMBER DEtAiLS

Persal/employee/pensionno Employer (on payslip)

Surname

Fullfirstname

Initials Title(Mr,Mrs,Ms,orother)

IDnumbernnnnnnnnnnnnnorPassportnumbernnnnnnnnnnnnn

Dateofbirthnnnnnnnn Nationality

Gender n M nFIncometaxnumbernnnnnnnnnnMarital status n Married n Single nDivorced nWidow/er n Co-habiting

Postaladdress

Code

Residential address

Code

Telno(H)() (W)()

Cellphone Faxno()

Email

D D M M Y Y Y Y

Name and surname 1of6

PLEASE REFER to tHE APPLiCAtion GUiDE to ASSiSt YoU WitH tHE CoMPLEtion oF tHiS FoRM. Do not REtURn tHiS GUiDE WitH YoUR CoMPLEtED APPLiCAtion FoRM.

PLEASE CoMPLEtE ALL tHE APPLiCABLE SECtionS CAREFULLY AnD in FULL.

Ensure that you provide all necessary supplementary documentation. Submit the completed application form to GEMS in any of the following manners:

Viafaxto0861004367,or Viaemailtoenquiries@gems.gov.za,or Via regionaloffices, or Postaladdress:GEMS,PrivateBagX782,CapeTown8000

Applicationfor Membership

FoR oFFiCE USE onLY

SECtion B: DEtAiLS oF DEPEnDAnt/S

PleaserefertoSectionBoftheapplicationguideinordertoensurethatthosepersonsyouwishtonominateasyourdependant/squalifyassuch.We cannot process your form if iD details are not provided. it is therefore compulsory to complete this section in full.

Surname Full first name Gender Date of birth iD or passport number

Country of issue Relationship

Basic income (if applicable)

SECtion C: BEnEFit oPtion

PleaseselectONLYONEBENEFITOPTIONfromthelistbelowandmarktheapplicableblockwithanX.

n Sapphire nBeryl n Ruby n Emerald nOnyx

All claim refunds are made at the Scheme rate and in accordance with the Scheme rules.

SECtion D: JoininG DAtE

PleaseindicatethedateonwhichyoustartedatyourcurrentemployernnnnnnnnPleaseindicatethedateonwhichyouwouldprefertojoinGEMSnnnnnnnn

SECtion E: inCoME CAtEGoRY

Employed applicantsPleaseindicateyourbasicmonthlysalary.Ifyouareatmiddleorseniormanagementlevel,pleaseindicateyourgrossmonthlypackage.(Includelatestpaysliporletterofappointmentifyouareanewemployee.)

Pensioner applicantsPleaseindicateyourbasicmonthlypension.

Monthly income R

Name and surname 2of6

D D M M Y Y Y Y

D D M M Y Y Y Y

Name and surname 3of6

SECtion F: PREVioUS MEDiCAL SCHEME MEMBERSHiP

Are you a member or dependant of a registered medical scheme? nYesn No

Ifyes,areyoutheprincipalmemberoradependant?n Member nDependant

If you are a member/dependant of another scheme, please attach your certificate of membership from your previous medical scheme that confirms the end date (membership cards are not sufficient). You must en-sure that your membership on your current medical scheme is cancelled before being covered by GEMS.

Name of previous medical scheme

Member number

PeriodofmembershipFromnnnnnnnn Tonnnnnnnn

SECtion G: MEtHoD oF PAYMEnt Active employees’ monthly contributions are deducted automatically from their salaries where applicable.

Pensioner members, please select only one payment method from the list below:

IwillbepayingmymonthlycontributionsinthefollowingmannernDebitordern Cash

IfyouchoosetopayviadebitorderyouneedtocompleteSectionH:Memberbankingdetailsbelow.

Ifyouchoosetopaycash,pleaseusethefollowingbankingdetailswhendepositingyourcontribution:

Bank:FNBBranchCode:204109Account Name: Government Employees Medical SchemeAccountNumber:62094049593Reference: Member number

SECtion H: MEMBER BAnkinG DEtAiLS

Bank account details required for the direct crediting of member refunds and the direct debiting of amounts due by me to the Scheme. We cannot process any refunds due to you should we not have your banking details on record.

Bankaccountnumber Nameofaccountholder

Nameofbank

Branchname Branchcode

Typeofaccount n Current n Savings nTransmission

Dateofsignaturennnnnnnn

Authorisedsignature Fullname

D D M M Y Y Y Y

D D M M Y Y Y Y D D M M Y Y Y Y

SECtion i: ConSEnt

Beingdulyauthorised,mydependant/sandIherebyauthorisethemedicalpractitionerand/orstaffmemberofthehospitalinwhosecareIam/mydependantsareormyhealthcareprovideroranyotherpersoninpossessionofanyinformation concerning my health or that of any of my dependants to supply:

i. AnyinformationthatGEMS,itsagentsand/orcontractedthirdpartiesneedinordertosettleanyclaimsubmittedbymeormydependant/stoGEMSand/oritsagents;

ii. GEMSand/oritsagents’casemanagerwithanyinformationthecasemanagerneedsinordertomanageservicesrenderedtomeormydependant/s;

iii. Thehealthcaremanagementwithanyinformation,onananonymousbasis,thatisrequiredforadministrativeandstatisticalpurposes,providedsuchinformationshallbetreatedasconfidentialatalltimes.

it is important to give GEMS and/or its agents your consent to negotiate with your doctor/s, hospital or any other healthcare provider in order to ensure that you receive optimal care, that is cost effective.

SignatureofPrincipalMember Datennnnnnnn

SECtion J: DECLARAtion

Ideclarethat:

Thecontentofthisformistrue,correctandcomplete.Shouldtherebeanynon-disclosureormaterialmisrepresentation,IunderstandthatmymembershipmaybeterminatedandImayberequiredtorefundtheScheme,anysumwhich,formyabuseofthebenefitsorprivilegesoftheScheme,wouldnothavebeendisbursedonmybehalf,subjecttoappealprocedures.

IhavemademyoptionchoiceandIhavesatisfiedmyselfwiththebenefitstructureandcontributionsunderthisoption.

IagreetofamiliarisemyselfwiththerulesoftheScheme.

Mybeneficiaries,withtheexceptionofmyspouse/partner,arefullyorpartiallydependentonmeandtotheextentthattheyarepartiallydependentonmedonotreceiveanannualincomemorethanthemaximumsocialpension amount applicable or they are not permanently employed at the date of signing this form.

IamawarethatGEMSmayimposegeneraland/orcondition-specificwaitingperiods,asprovidedforintheMedicalSchemesAct(131of1998).

Iunderstandthatmypersonaldetailsandmedicalinformation(obtainedfromhealthcareproviderswithmyexplicitconsent)shallbekeptconfidential.

Iamawarethatmyandmydependants’confidentialhealthandpersonalinformationmaybeusedforresearch,statistical data, managed care and reporting purposes and any deviation from this constitutes a breach of confidentiality.

IunderstandthatintheeventthatGEMSwishestousemyormydependants’confidentialinformationforpurposes other than those outlined in this declaration, GEMS is required to obtain further consent from me and my dependants.

Iunderstandthatmypersonalandhealthrelatedinformationwillnotbeusedforpurposesofrelatedbusinessnor sold for commercial purposes.

IunderstandthatGEMShasgrantedaccesstocertainpersonswithintheorganisationanditscontractedthirdparties to members’ personal and health related information.

IunderstandthatGEMSanditscontractedthirdpartieswillusethemedical/health/diagnosis/procedureinformation provided for the following purposes: processing the application for membership, re-imbursement of claims,determiningmemberentitlementtobenefitsandriskmanagementpractice.

Name and surname 4of6

D D M M Y Y Y Y

Name and surname 5of6

SECtion J: DECLARAtion ContinUED IunderstandthatGEMShasenteredintoconfidentialityagreementswithallcontractedthirdpartieswhohaveaccesstobeneficiaryinformationforthepurposesofdatatransferandmanagement,schemeadministrationand managed care arrangements.

IunderstandthatallstaffwithinGEMSanditscontractedthirdpartiesareboundbyinternalconfidentialityagreements.

IunderstandthatGEMSwillensurethatadequatedatasecuritymeasuresareinplace.

Iunderstandthatintheeventofabreachinconfidentiality,GEMSassumesresponsibilityandthebreachwillbe managed according to GEMS’s internal protocols.

Iundertaketosubmitmyselfandmydependant/stotheGEMSrulesandprotocols.

IherewithirrevocablyauthoriseGEMStoimplementthepaymentofmonthlycontributionswithimmediateeffectfrommyjoiningdate.

I,asamemberofGEMS,amliableforpaymentofmonthlycontributionstoGEMS.

Iherewithirrevocablyauthorisemyemployer/GEMStorecoverfrommysalary/bankaccountanyamountImaylegally owe GEMS and to pay over to GEMS or its agents all amounts thus recovered.

IacknowledgethatIamawarethatGEMSmayinstitutedebtmanagementactivities,asprovidedforintherulesoftheScheme,againstmeintheeventthatIdefaultonthepaymentofcontributionsoranyotheramounts due to GEMS.

NeitherInoranyofmydependantsarebeneficiariesofanotherregisteredmedicalscheme.

IwillinformtheSchemeofanychangesinmydependant’shealthorpersonalstatus,asrequiredbytherulesoftheScheme,within30daysofthechangeincircumstances.

IwillnotifyGEMSatleast48hoursbeforeanon-emergencyhospitaladmission.Iacknowledgethatfailuretodo so will result in a co-payment by myself.

IacknowledgethatGEMSoritsagentswillonlymakeclaimspaymentsthatitdeemstobevalidandinaccordance with the Scheme rules.

RulesshallatalltimesremainineffectandIacceptthatletters,newslettersandbookletsdonotreplacetheScheme rules.

IagreethatallconversationsbetweenmeandtheSchemeoritscontractedpartiesmayberecorded.

SignatureofPrincipalMember Datennnnnnnn

D D M M Y Y Y Y

SECtion k: DECLARAtion BY GEMS

the Scheme declares that:

Amember’spersonaldetailsandmedicalinformation(obtainedfromhealthcareproviderswiththeexplicitconsentofthemember)shallbekeptconfidential.

Member information (personal and health information) will not be used for purposes of related company business nor sold for commercial purposes.

Therearedatasecuritymeasuresinplace.

Access is granted to persons within the organisation and its contracted third parties, to the personal and health informationofbeneficiaries.

TheSchemeanditscontractedthirdpartieswillusethemedical/health/diagnosis/procedureinformationprovided for the following purposes: processing the application for membership, re-imbursement of claims, determiningmemberentitlementtobenefitsandriskmanagementpractice.

AllstaffmemberswithintheSchemeanditscontractedthirdparties,areboundbyinternalconfidentialityagreements.

TheSchemehasensuredthatconfidentialityagreementshavebeenenteredintowithallcontractedthirdpartieswhohaveaccesstobeneficiaryinformationforthepurposesofdatatransferandmanagement,Schemeadministration and managed care arrangements.

Intheeventofabreachofconfidentiality,theSchemeassumesresponsibilityandthebreachwillbemanagedaccording to the Scheme’s internal protocols.

Please call 0860 00 4367 should you not have received confirmation of your membership on GEMS within7 working days from the date of submission of your application.

Name and surname 6of6

Postal address:GEMS,PrivateBagX782,CapeTown8000

Please do not return this guide with your completed application form.

We have highlighted the important information in the various sections of your application form that will assist you in completing your application form correctly. Please read the guide carefully.

Please make sure that you also supply the following supplementary documentation for the Principal Member:

1.CopyofIDforPrincipalMember2. M2 form which is to be submitted with application form when you need to change your medical scheme

particulars and to continue receiving your same subsidy3.Z583formsifyouareretiringandneedtoapplyforcontinuationofmembershiporifyouareadependantwhoneedstocontinuemembershipuponthedeathofthePrincipalMember

4.SubsidyconfirmationletterfromNationalTreasury,ifavailable5.Membershipcertificatefromthepreviousmedicalschemewithanenddate6.Yoursignaturewhererequired(SectionsH,IandJ)

CoMPLEtinG YoUR APPLiCAtion FoRM

SECtion A: MEMBER DEtAiLSit is compulsory to complete all information in Section A, where applicable.

Persal/employee/pension numberYourPersalnumberisavailableonyoursalaryadvice.

PensionersPleaseprovideyourpensionnumberthatappearsonyourcorrespondenceorPensionCertificatefromtheNationalTreasury.

EmployerPleaseindicateyourcurrentemployer’snameandorganisationcode.Yourorganisationcodecanbeobtainedfromyour salary advice, if you are a civil servant.

SECtion B: DEtAiLS oF DEPEnDAnt/SPleasecompletethedetailsofyourdependant/sinSectionBoftheapplicationform.

it is compulsory to complete the iD details of your dependants in this section. We will be unable to process your application if this information is not provided.

Nodependants,otherthanthoselistedinthetablebelow,areeligibleformembership.ThefollowingdocumentationisrequiredwithanapplicationifthePrincipalMemberwishestoregisterbeneficiariesasdependants:

Spouse Completed dependant section on application form.•Ifcustomarymarriage,anaffidavitfromthememberconfirmingtheobligation•towards the spouse.MarriagecertificaterequiredifmarriedandsurnamediffersfromPrincipalMember.•

Ex-spouse Completed dependant section on application form.•Copy of legal obligation to provide medical support per divorce settlement or court •ordertosucheffectexisting.

Partner • Completeddependantsectiononapplicationform.• Swornaffidavitconfirmingthatthedependantisthemember’slifepartner.(SwornaffidavittobecompletedbyPrincipalMember,partnerandwitness)

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Guide to Completingand Submitting Your Application Form

DESCRiPtion oF DEPEnDAnt DoCUMEntAtion REqUiRED

Child (biological, adopted, step or foster),withPrincipalMember’ssurname, under the age of 21

Completed dependant section on application form.•note:Ifthechild’ssurnamediffersfromthePrincipalMember’s,anaffidavitconfirmingtheobligationtowardsthechildandstatingthereasonforthedifferenceisrequired.(SwornaffidavittobecompletedbyPrincipalMember)note:• Thespousemustberegisteredtoaddthestepchild.

Child (biological, adopted, step or foster), over the age of 21

Completed dependant section on application form.•Ifchildisastudent:•Proofoffull-timeregistrationatarecognisedtertiaryinstitutionand -AffidavitfromPrincipalMemberconfirmingfinancialdependency. -

Ifchildistotallydependentduetomentalorphysicaldisability:•Proofofdisabilityfromamedicalpractitioner(Medicalassessmentreporttobe -completedbyMedicalPractitioner)andAffidavitfromPrincipalMemberconfirmingfinancialdependencyandthatthe -child is not in a state institution.

Ifchildisnotastudentnordisabled:•AffidavitfromPrincipalMemberconfirmingfinancialdependency. -

note:• Thespousemustberegisteredtoaddthestepchild.

Dependantwithdifferentsurname Ifdependant’ssurnamediffersfromthePrincipalMember’s,anaffidavitconfirming•thePrincipalMember’sobligationtowardsthedependantandstatingthereasonfordifferenceisrequired.(SwornaffidavittobecompletedbyPrincipalMember)

Child in-law Completed dependant section of the application form.•AffidavitfromPrincipalMemberconfirmingfinancialdependencyofthe•beneficiaries.note:• Thechildofthememberorthememberorthemember’sspousemustberegistered to add the child in-law.

Parents,parents-in-law,grandparentor grandparents-in-law

Completed dependant section on application form.•AffidavitfromPrincipalMemberconfirmingfinancialdependencyofthe•beneficiaries.note: • Parents-in-lawandgrandparents-in-lawmayonlyberegisteredifthespouseisalsoregisteredasabeneficiary.

Grandchild, great grandchild and so forth

Completed dependant section of the application form.•ProofofchildsupportgrantreceivedbythePrincipalMemberorthespouse,or•SwornaffidavitconfirmingfinancialdependencyofthegrandchildonthePrincipal•Member.(SwornaffidavittobecompletedbyPrincipalMemberandbiologicalparent, where applicable)note:• IftheparentofthechildisalsoregisteredasadependantanaffidavitisneededfromthePrincipalMemberforthegrandchildorgreatgrandchildonly.

Sibling, half sibling, step sibling and in-law sibling

Completed dependant section of the application form.•SwornaffidavitconfirmingfinancialdependencyofthesiblingonthePrincipal•Member.(SwornaffidavittobecompletedbyPrincipalMember)note: • ThesiblingofaPrincipalMemberorthePrincipalMember’sspousemayberegisteredasabeneficiary.note:• Thespousemustberegisteredtoaddhis/hersiblings.

Children of sibling Completed dependant section of the application form.•Swornaffidavitconfirmingfinancialdependencyofniece/sand/ornephew/sonthe•PrincipalMember.(SwornaffidavitmustbecompletedbythePrincipalMemberand sibling, where applicable)note:• ThechildrenofasiblingofaPrincipalMemberorthePrincipalMember’sspousemayberegisteredasabeneficiary.note:• IftheparentofthechildisalsoregisteredasadependantanaffidavitisneededfromthePrincipalMemberfortheniece/nephewonly.

note ID documents or birth certificates are required for all dependants.•

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DESCRiPtion oF DEPEnDAnt DoCUMEntAtion REqUiRED

Adultdependantratesarepayableforalldependantsovertheageof21,excluding- Disableddependants(childratesarepayable);- Childrenwhoarestudents(childratesarepayableuntiltheageof27);

Pleasenotethatyouradultdependant/smaybesubjecttoanannualeligibilityreview.Membersmustprovideannualproofofdependencyofallbeneficiariesovertheageof21(excludingdisableddependants).

The affidavits mentioned in the table above, as well as the medical questionnaire for disabled dependants, are available on the GEMS website at www.gems.gov.za or can be obtained by phoning the Call Centre on 0860 00 4367.

What you need to do if you have to provide GEMS with the following documents:

Affidavits Ifyouhavetosubmitanaffidavityouneedtogotoyournearestpolicestationoranypersonauthorisedasa

commissioner of oaths to certify that the information you are providing to GEMS is true and correct.

Medical report TaketheAssessmentReportbyMedicalPractitioner(Disability)Formtotheapplicablemedicalpractitionerandrequesthim/hertocompletetheform.TheconsultationwillbecoveredfromtheGPconsultationbenefitforregisteredmembers.Unregisteredmembersarerequiredtocoverthecostofthisconsultationoutoftheirownpockets.

SECtion C: BEnEFit oPtion Pleasemakeyourselectioncarefully,asyouarenotabletochangeyouroptionduringthecourseoftheyearwithouttheapprovaloftheBoardofTrustees. Yourout-of-hospitalandotherblockbenefitswillbepro-ratedifyourentrydateisnotthe1stofJanuary.Thismeansthatyourbenefitlimitswillbecalculatedinproportiontotheperiodofmembershipleftfortheyearfromyourdateofjoining. Youwillbeabletochangeyouroptionattheendofeachyearwitheffectfromthefirstdayofthefollowingyear.

SECtion D: JoininG DAtEYouneedtoindicatethedateyouwishtojoinGEMSinSectionDoftheApplicationform.

Please take note of the following: Youradmissiondatemustbeonthefirstdayofamonth. Where possible, ensure that your admission date at GEMS directly follows the cancellation date of your previous medicalscheme,asabreakinmembershipmaynegativelyimpactonyouremployersubsidy. Ifnodateisentered,yourregistrationdatewillbeautomaticallydeterminedforthefirstdayofthenextmonthsothat no arrear contributions are created. Ifthejoiningdateselectedbyyoucausesarrearcontributions,itwillbedeductedfromyoursalaryorbankaccount (where applicable). Inrespectofnewemployees,yourregistrationdatecannotbeearlierthanyourappointmentdate.

SECtion E: inCoME CAtEGoRYPensioner ApplicantsPleasefillinanM2formandZ583formforconfirmationofsubsidywiththeNationalTreasuryDepartment.TheseformscanbeobtainedfromtheGEMSwebsiteatwww.gems.gov.zaorbycallingtheCallCentreon0860004367.ShouldyouhaveacopyofaNationalTreasuryletterconfirmingyoursubsidy,pleaseattachittotheapplicationform,asitwillallowforamoreefficientregistrationprocess.

Employed ApplicantsPleaseindicateyourbasicmonthlysalary.Ifyouareatmiddleorseniormanagementlevel,pleaseindicateyourgrossmonthlypackage.(Includelatestpaysliporletterofappointmentifyouareanewemployee.)

SECtion F: PREVioUS MEDiCAL SCHEME MEMBERSHiPPleaseattachamembershipcertificatewithanenddatefromyourpreviousmedicalscheme.

Please note the following: Legislationdeterminesthatyouoryourdependantsmaynotberegisteredontwomedicalschemesatthesame

time.3of6

What you need to do if you belonged to a previous medical scheme prior to joining GEMS: Pleasecontactyourpreviousmedicalschemeandrequestthemtoprovideyouwithamembership certificate

with an end date as proof of membership. Pleasenotethatifyourmembershipcertificatedoesnotreflectanenddate,weareunabletouseit.Remember

to complete and forward a termination letter to cancel your membership with the previous medical scheme, if you have not done this yet.

Ifyouareunabletoobtainamembershipcertificate,wewillacceptaterminationofmembershipletteronyourprevious medical scheme’s letterhead, as proof of resignation.

SECtionS G AnD HItiscompulsorytocompletethesesectionsinfull,asyourapplicationformwillnotbeprocessedifbankingdetailsare not provided.

SECtionS i AnD JPleaseensurethatyoureadthesesectionscarefullybeforeyousignthesesectionsonyourapplicationform.

Please note: Your application form will not be processed without your signature.

ADDitionAL inFoRMAtion FoR REGiStERinG MEMBERS

GEMS nEtWoRk oPtionSIfyouchoosetojointheSapphireorBeryloption,youneedtonotethatthesearenetworkoptions.ThismeansthatyouandyourdependantsarerequiredtouseonlyhealthcareproviderscontractedtotheGEMSNetwork.Yourcurrentfamilydoctor/dentist/optometristmaynotbelistedasaGEMSNetworkprovider.Ifthisisthecase,youneedtocalltheGEMSCallCentreon0860004367tofindaserviceproviderinyourarea.

FRiEnDS oF GEMSGEMS has partnered with thousands of doctors, dentists and other healthcare service providers to offer members aninnovativeproviderregistrythatbringshealthcareproviderswithinmembers’reach.Theseprovidershaveagreed not to charge GEMS members above the Scheme’s rate, which means that you do not have to pay anything outofyourownpocketforaconsultationwitha“FriendofGEMS”.

Tofinda“FriendofGEMS”inyourarea,simplysendanSMSto33489withyourmembernumber,theserviceprovidercategory,thesuburband/orextensionandtownyourequire.

ForexampleifyouliveinHillcrest,Pretoriaandyouneedtoseeageneralpractitioner(GP),yourSMSshouldlooklikethis:123456789,GP,Hillcrest,Pretoria.Youwillreceiveaninstantresponsewiththedetailsoftheproviders,forexample“DrADlamini,103KingsleyCentre,ChurchStreet,0121234567”.SMSesarecompetitivelypricedatR1.50andtheresponseSMSisincluded.this service applies to all options.

HiV/AiDSIfyouoranyofyourdependantsarelivingwithHIV/AIDS,itwouldbeinyourinteresttojointheGEMSHIV/AIDSManagementProgrammebycallingAidforAIDSon0860100608.Thisisaconfidentialprogramme,neithertheemployer nor the Scheme has access to the participant’s information.

CHRoniC MEDiCAtionChronicmedicinesareprescribedtotreatongoingconditionssuchashighbloodpressureorasthmaandaretakencontinuously.

GEMSprovidescomprehensivechronicmedicinebenefitstoallmembers.InordertoqualifyforyourchronicmedicineyouhavetoregisterontheMedicineManagementProgramme,afteryouhavereceivednotificationthatyou are a registered member of GEMS.

Chronic medicines include: Medicineforlife-threateningillnesses,likediabetes; Medicineusedonanongoingbasistotreatdisablingchronicillnessesthatsignificantlyaffectproductivityandqualityoflife;and Expensiveshort-termmedicinethatwillpreventotherexpensivetreatment,likehospitalisation.

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APPLiCAtion FoR CHRoniC MEDiCAtion

Sapphire and BerylIfyouareontheSapphireorBeryloption,yourGEMSNetworkdoctor,afterconfirmingyourdiagnosis,willberesponsible for registering your condition with GEMS and obtaining authorisation for your chronic medication.

Onceregisteredontheprogrammeyourauthorisedmedicationwillbecoveredinfull,providedthatyouobtainthemedicationthroughthedesignatedcourierpharmacy(Medipost).YourGEMSNetworkdoctorwillassistyouwiththese arrangements.

PleasenotethatonlymedicationontheSapphireandBerylmedicationformularyiscovered.

Ruby, Emerald and onyxIfyouareontheRuby,EmeraldorOnyxoption,youneedtoapplyforyourchronicmedicinebyobtainingaChronicMedicineBenefitApplicationFormfromtheGEMSCallCentreordownloadingonefromourwebsiteat www.gems.gov.za.

Onceyourdoctorhasexaminedyouandcompletedtheapplicationform,youneedtofaxtheformtogetherwitharepeatabledoctor’sprescriptionto0866518009forprocessing.AlternativelyyoumayemailthesetochronicDSP@gems.gov.za.Alwaysensurethatyourapplicationhasbeenfilledoutcompletelyandsignedbybothyourself and your doctor.

A clinical team will then review your details and if necessary will contact your doctor (either telephonically or in writing)inordertoselectmoreappropriateand/orlesscostlymedication.AnSMSwillbesenttoyouindicatingthestatusofyourapplication(receiptandapproval).Yourrequestwilltakeapproximatelysevenworkingdaystoprocess.

Please remember the following when applying for chronic medicine: A separate chronic application form has to be completed for each family member who needs chronic medicine. Keepacopyofyourcompletedformforyourownrecords. Attachsupportingtests/specialinvestigationsandmotivations(asrequired)topreventdelaysintheprocessingof your application.

OnceyourapplicationhasbeenapprovedyouwillreceiveanauthorisationletterlistingthemedicinestobepaidfromyourChronicMedicineBenefit.TheletterwillalsoindicatewhichmedicinesareontheapprovedMedicinePriceList(MPL)andthosemedicinesthatwillattractout-of-formularyco-payments.Alternatives,whichwon’tattractaformularyco-payment,areavailable.Pleasediscussthepossibilityofusinganalternativeproductwithyourprescribingdoctorshouldyouwishtoavoidthisco-payment.Iftheauthorisedmedicinediffersfromthemedicinerequested,aletterofexplanationwillbeincludedwithyourauthorisationletterandacopywillbesenttothe prescribing doctor.

Ifyourapplicationisdeclined,aletterwillbesenttoyouandacopywillbesenttoyourprescribingdoctor.Iffurther clinical information is required, your request will be reconsidered once all the relevant information has been receivedfromyourdoctor.Yourdoctormaycall0860100608forassistance.

Update applicationsIfyourchronicmedicationchangesinanyway,youneedtoinformGEMS.Pleasefaxarepeatabledoctor’sprescriptionforthenewmedicationtotheGEMSchronicdesignatedserviceprovider(DSP)on0866518009.

Medication deliveryAGEMSchronicDSPconsultantwillcontactyouwithin48hoursofsubmissionofyourdoctor’ssubscriptionfornewmedicationtomakearrangementsfordeliveryofyourmedication.

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SUBMittinG YoUR CoMPLEtED APPLiCAtion FoRMOnceyouhavecompletedyourapplicationform,youcansubmititforregistrationinanyofthefollowingmanners:

Faxitto0861004367,or

Emailittoenquiries@gems.gov.za,or

Dropitoffatanyofthefollowingregionaloffices: FREE StAtE • Bloemfontein:BloemPlaza,Shop124,MaitlandStreet • Welkom:LibertyCentre,Shop24,MooiStreet LiMPoPo PRoVinCE • Polokwane:Shop1,52MarketStreet • Thohoyandou:UnitG3,MetropolitanCentre EAStERn CAPE • EastLondon:13ASurreyRoad,Vincent • Mthatha:SavoyComplex,Unit11&12A,NelsonMandelaDrive noRtHERn CAPE • Kimberley:NewParkCentre,Shop14,c/oBultfonteinWay&LawsonStreet • Upington:61AMarkStreet MPUMALAnGA • Nelspruit:24c/oMurray&VanderMerweStreets • eMalahleni(Witbank):SafewaysCrescentCentre,ShopS67,c/oPresident&SwartbosStreets,DieHeuwel noRtH WESt • Klerksdorp:CityMall,Shop15A,c/oORTambo&NeserStreets • Mafikeng:MmabathoMegacityShoppingCentre,Shop39,c/oSekame&JamesMorakaStreets,Mmabatho kWAZULU-nAtAL • Durban:TheBereaCentre,ShopG18,Entrance1,249BereaRoad,Berea • Pietermaritzburg:DeloitteHouse,Suite3,BlockA,181HoosenHaffejeeStreet(BergStreet) GAUtEnG • Johannesburg:TradunaHouse,118JorrisenStreet,GroundFloor,c/oJorrisenandCivicBoulevard (opposite Civic Centre) • Pretoria:SancardiaBuilding,Shop51,FirstFloor,c/oBeatrix&ChurchStreets,Arcadia WEStERn CAPE • Worcester:MountainMillShoppingCentre,Shop125A&B,MountainMillDrive • CapeTown:ConstitutionHouse,124AdderleyStreet

PostittoGEMSatPrivateBagX782,CapeTown,8000

Uponprocessingofyourapplicationform,youwillreceiveanSMStoconfirmreceiptofyourapplication.Youwillbeinformed accordingly should any additional documents be required to complete the registration of your application.

Uponcompletionoftheregistrationofyourapplicationform,amemberpackthatincludesyourmembershipcardsand a comprehensive member guide will be posted to your postal address.

Postal address:GEMS,PrivateBagX782,CapeTown8000

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