URGENT ESCALATION: GEMS FAILURE TO RESPOND TO MEDICATION AUTHORISATION – ONGOING TREATMENT AND PMB CONCERNS

I am lodging this complaint because GEMS has failed to provide me with a substantive response to my previous request concerning the authorisation of my medication.

I previously contacted GEMS and specifically requested:

1. Tegrenol instead of Degranol

The pharmacy has confirmed that Degranol is currently unavailable and is not even available from its supplier. I therefore requested that GEMS urgently authorise Tegrenol as an alternative so that there is no interruption to my treatment.

2. Baclofen

I have already submitted the required Ex Gratia documentation for Baclofen. Despite the documentation having been submitted, I am still waiting for an outcome. I have received no clear decision explaining whether the medication will be authorised or declined.

What is particularly concerning is that I have now followed up with GEMS and have still not received a meaningful response.

This is not simply an administrative query. These medications form part of my ongoing medical treatment, and delays in authorisation directly affect my ability to access the treatment prescribed to me.

I am also concerned because I am already involved in an ongoing dispute with GEMS regarding my PMB registration and access to treatment and medication related to my registered condition. I have repeatedly had to challenge GEMS regarding claims and medication authorisations, and I do not believe that I should have to continuously fight for access to treatment that I am entitled to receive under my benefits.

I therefore require GEMS to provide a substantive written response, not another generic acknowledgement or statement that the matter has been referred to another department.

Specifically, I require GEMS to:

1. Confirm whether Tegrenol will be authorised as an alternative to Degranol, taking into account the pharmacy's confirmation that Degranol is unavailable from both the pharmacy and its supplier.

2. Provide an immediate written outcome regarding my Baclofen Ex Gratia application, including the reasons for the decision if it is declined.

3. Confirm whether these medications are being considered under my applicable PMB benefits, where applicable, and clearly explain the benefit category under which each medication is being assessed.

4. If GEMS refuses or declines either medication, provide the specific clinical, benefit and/or Scheme Rule reasons for the decision rather than simply stating that the medication is not covered.

5. Confirm what steps GEMS is taking to ensure that I do not experience an interruption in my ongoing treatment while the authorisation matter is being resolved.

6. Provide me with the name or department responsible for the outstanding authorisation and a clear timeframe for finalisation.

7. Review my previous correspondence and provide one consolidated response addressing the actual issues I raised.

I want to make it clear that I do not want another generic response advising me to contact the pharmacy, submit documents that I have already submitted, or wait for another department to respond.

GEMS has already been provided with the relevant information and documentation. I am asking for an actual decision, reasons for that decision, and confirmation of the benefit basis on which the decision has been made.

The continued lack of response is unacceptable, particularly where the matter concerns access to prescribed medication and ongoing medical treatment.

I request that this complaint be urgently escalated to a senior official within GEMS and that I receive a substantive written response addressing each of the points above.

Should GEMS maintain that any of these medications are not covered or cannot be authorised, I request that this position be provided to me in writing, together with the reasons and applicable Scheme Rule/benefit provisions, so that I can take the matter further through the appropriate dispute-resolution process.

I expect GEMS to treat this matter with the urgency it deserves.