Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: Essence Healthcare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don’t get approval, Essence Healthcare may not cover the drug.
- Quantity Limits: For certain drugs, Essence Healthcare limits the amount of the drug that Essence Healthcare will cover. For example, Essence Healthcare provides 18 tablets per prescription for sumatriptan tablets. This may be in addition to a standard one month or three-month supply.
- Step Therapy: In some cases, Essence Healthcare 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 Healthcare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Essence Healthcare to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Essence Healthcare formulary?” on page iv 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 (list of covered drugs), you should first contact customer service and ask if your drug is covered. If you learn that Essence Healthcare 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 Healthcare. 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 Healthcare.
- You can ask Essence Healthcare to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the Essence Healthcare (HMO) Formulary?
You can ask Essence Healthcare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
- You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Essence Healthcare 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 a greater amount. Generally, Essence Healthcare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing 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 should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) 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 a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply.
If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. vi If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. Examples include beneficiaries who are entering a long-term care facility, are discharged from a hospital to home, or ending a long-term care stay and returning to the community.
For more information
For more detailed information about your Essence Healthcare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Essence Healthcare, please contact us.