How are GEMS medicine co-payments calculated?
Here is the instruction given to GEMS patients:
Medicine co-payments with GEMS are calculated based on different scenarios:
1. Non-DSP Co-payment: If you get your medicine from a pharmacy other than the one you nominated, you will have to pay 30% of the price of the claim for the chronic medicine.
2. MPL Co-payment: This occurs when you choose a medicine priced higher than the GEMS maximum price for that medicine, for which there is a generic equivalent available. The co-payment is the difference between the price of the medicine you choose and the GEMS MPL price.
3. Out-of-Formulary Co-payment: This happens when the medicine you receive is not listed on the GEMS formulary specific to your option. This co-payment can apply either when your benefits have been exhausted for the year or throughout the year regardless of available benefits.
To avoid these co-payments, it’s important to get your medicine from the nominated pharmacy, choose medicines within the MPL price range, and ensure the prescribed medicine is on the formulary specific to your option.