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Essence St. Louis Part D Medicare Prescription Drug Plan
2008 Prescription Drug Formulary
We have a formulary that lists all drugs we cover. Both brand-name drugs and generic drugs are included on the formulary. A generic drug has the same active-ingredients as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs.
Drugs on our formulary are organized into different drug tiers, or groups of different drug types. Your co-insurance/co-payment depends on which drug tier your drug is in. Refer to the tables on the Paying for Your Prescription Drugs page which show the co-insurance/co-payment amount you pay for each tier when you are in your Initial Coverage Period.
Not all drugs are included in the formulary. In some cases, the law prohibits coverage of certain types of drugs. In other cases, we have decided not to include a particular drug. You can get updated information about the drugs we cover by viewing the formulary.
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Transition Policy
Essence has developed a transition process for new members who are transitioning to a Part D plan from other prescription drug coverage, including other Part D plans, and whose current drug therapies may not be included in our formulary. Click Here for more information about Essence's .
Can the Formulary Change?
Generally, if you are taking a drug on our 2008 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2008 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or improve the safety of your drugs.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by Essence, view the formulary on this website or call Customer Service at the numbers listed below.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits include:
- Prior Authorization: Essence requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from Essence before you fill your prescriptions. If you don't get approval, Essence may not cover the drug.
- Quantity Limits: For certain drugs, Essence limits the amount of the drug that Essence will cover. For example, Essence provides 15 tablets per prescription for ZOFRAN. This may be in addition to a standard one month or three month supply.
- Step Therapy: In some cases, Essence requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Essence may not cover drug B unless you try Drug A first. If Drug A does not work for you, Essence will then cover Drug B.
You can ask Essence to make an exception to these restrictions or limits. See Appeals & Grievances, Exceptions & Coverage Determinations on this website for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Customer Service and ask if your drug is covered. If you learn that Essence does not cover your drug, you have two options:
- You can ask Customer Service for a list of similar drugs that are covered by Essence. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Essence.
- You can ask Essence to make an exception and cover your drug. (See Appeals & Grievances, Exceptions & Coverage Determinations on this website.)