< Return to Prescription Drug SearchLA: Limited Access. This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or call customer service at 1-866-509-5396 toll free, seven days a week from 8am to 8pm. You may reach a messaging service on weekends and holidays from April 1 through September 30. Please leave a message, and your call will be returned the next business day. TTY users should call 711.
NDS: Non-Extended Days’ Supply. This drug can only be obtained for a one-month supply or less. You cannot fill a prescription for more than a one-month supply.
NM: Non-Mail Order. The prescription cannot be filled by an Essence Healthcare network mail order pharmacy. vii PA: 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 Essence Healthcare before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug.
PA BvD: Prior Authorization for Part B vs Part D Determination. This prescription drug has a Part B versus D administrative prior authorization requirement. You (or your physician) are required to get prior authorization from Essence Healthcare to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, the plan may not cover this drug.
PA-HRM: Prior Authorization, High Risk Medications. This prescription drug has been deemed by CMS to be potentially harmful and therefore, a High-Risk Medication for Medicare beneficiaries 65 years of age or older. Members age 65 years or older are required to get prior approval from Essence Healthcare before filling prescriptions for this drug. Without prior approval, the plan may not cover this drug.
NSO: Prior Authorization, New Starts Only. If you are a new member or if you have not taken this drug before, you or your physician are required to get prior authorization from Essence Healthcare before you fill your prescription for this drug. Without prior approval, the plan may not cover this drug.
QL: Quantity Limit. For certain drugs, Essence Healthcare limits the amount of the drug that the plan will cover. For example, Essence Healthcare provides eighteen tablets per prescription for sumatriptan succinate. This may be in addition to a standard one-month or three-month supply.
ST: 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.
Essence Healthcare is an HMO plan with a Medicare contract. Enrollment in Essence Healthcare depends on contract renewal. All Essence plans include Part D drug coverage. To enroll, you must have both Medicare Parts A and B and reside in the Missouri counties of Boone, Jefferson, St. Charles, St. Louis or St. Louis City, or in the Illinois counties of Madison, Monroe or St. Clair.
You must continue to pay your Medicare Part B premium. Please note that enrollment is limited to specific times of the year. This information is not a complete description of benefits. Call 1-866-509-5398 (TTY: 711) for more information. Members must use plan providers except in emergency or urgent care situations. If a member obtains routine care from an out-of-network provider without prior approval from Essence, neither Medicare nor Essence will be responsible for the costs.
For accommodations of persons with special needs at meetings call 1-866-509-5398 (TTY: 711).
Medicare beneficiaries may also enroll in Essence Healthcare through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
Essence Healthcare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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