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Essence Washington Part D Medicare Prescription Drug Plan
Appeals & Grievances, Exceptions & Coverage Determinations
We encourage you to let us know right away if you have questions, concerns, or problems related to your prescription drug coverage. Please note that this page and your Evidence of Coverage addresses complaints about your Part D prescription drug benefits. If you have complaints about your medical services and benefits, see Grievances & Complaints under the "Information for Members" section of this web site.
Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Essence or penalized in any way if you make a complaint.
A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint.
What is a Grievance?
A "grievance" is any complaint other than one that involves your Part D prescription drug benefits. You would file a grievance if you have any type of problem with Essence or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, disrespectful or rude behavior by medical staff, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a doctor's office. For more information about grievances, including how to file a grievance, see Grievances & Complaints on this website.
What is a Coverage Determination?
A "coverage determination" is the first step in dealing with requests you may have about Part D prescripton drug coverage. If your doctor or pharmacist tells you that a certain prescription drug is not covered, you must contact Essence if you want to request a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide the prescription drug you are requesting or pay for a prescription drug you have already received. You have the right to ask us for an "exception", which is a type of coverage determination, if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. For more information about coverage determinations and exceptions, see your Evidence of Coverage. To ensure we are provided with the information necessary to make a coverage determination, please download the Request for Medicare Prescription Drug Determination Request Form (for use by enrollees) from CMS's website. The completed form should be mailed to:
Essence Healthcare
PO Box 12488
St. Louis, MO 63132-0188
What is an Appeal?
An "appeal" is any of the procedures that deal with the review of an unfavorable coverage determination. You cannot request an appeal if we have not issued a coverage determination. If we issue an unfavorable coverage determination, you may file an appeal called a "redetermination" if you want us to reconsider and change our decision. If our redetermination decision is unfavorable, you have additional appeal rights. For more information about appeals, see your Evidence of Coverage.
An Essence member (enrollee) can appoint a representative to file an appeal on his or her behalf. To be appointed by an enrollee, both the representative and enrollee must sign, date, and complete Form CMS-1696 - Appointment of Representative Form which can be obtained from the Centers for Medicare & Medicaid Services (CMS) website. See Instructions for Appointing a Representative. After completing the form, please mail or fax to Member Services.
What is an Exception?
An "exception" is a type of coverage determination. You can ask us to make an exception to our coverage rules in a number of situations:
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Essence limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
Generally, Essence will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You can find a list of Pharmacy Request Forms on this website.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.
For more information about coverage determinations and exceptions, see your Evidence of Coverage.
Refer to Essence's Drug Transition Policy on this website about what to do before talking to your doctor about changing your drugs or requesting an exception.