Provider Pulse

Your lifeline to Essence news and resources

Do you have practice changes to report to Essence? Complete the Provider Demographic form if you’re changing an address (physical location or billing) or NPI number (adding or removing providers). Visit the Provider Portal to review all the details and to access the form.

Medicare Annual Enrollment Period—Provider Resources

The Medicare Annual Enrollment Period begins on October 15 and runs through December 7. This is an opportunity for your Medicare patients to explore options and think about their healthcare needs for the upcoming year. Review our Talking Medicare Guide for a quick summary of how to compliantly discuss Essence with your patients.

Coming Soon! Our Provider Services team will host a 2026 benefit overview in Q1. Be sure to check back for event details.

Provider Satisfaction Survey—Your Voice Matters

Watch for an email in late September from Press Ganey with a link to complete the 2025 Provider Satisfaction Survey. We encourage you to participate to help us continue building on our progress to support you. Thanks to your suggestions in last year’s survey, we’re making three important changes to reduce your administrative responsibilities and enhance your experience with us.

For questions about the survey please send an email to providerservices@lumeris.com.

Health Outcomes Survey (HOS): Valuable Tool for Patient Care

Essence Healthcare is participating in the annual HOS to further our ongoing commitment to enhancing patient care and improving health plan outcomes. Use our Provider Tip Guide to stay informed about fall risk, mental health, physical activity and urinary incontinence. You’ll find a list of questions to ask your patients, educational videos and more.

Our Healthy Living Hub educates our members on these topics as well.

Register for Our Provider Expo

Join us this September for our first-ever Provider Expo—a dedicated event designed to bring our network together, share key updates and enhance how we serve Essence members. This informative, interactive session will include:

  • Important updates to policies and procedures
  • Best practices for collaborating with Essence
  • A chance to connect with Essence team members and vendors
  • Opportunities to ask questions and share feedback

Register Today

Managing New Part D Star Measures for Remainder of 2025

The Concurrent Use of Opioids and Benzodiazepines (COB) and Polypharmacy - Use of Anticholinergic Agents (Poly-ACH) are two new measures introduced this year that aim to reduce harm by identifying patients taking potentially dangerous combinations of medications and prompting providers to address the risks. The Essence monthly gap in care tracker helps highlight your at-risk patients for clinical review and intervention. The evaluation of all clinical alternatives is recommended before initiating new prescriptions of these high-risk medications.

Strengthening Community Connections

By teaming up with trusted organizations we’re making a positive impact on the health of our members and our community. We’ve partnered with the following organizations to sponsor food delivery, a community fair, classes and to provide disaster relief support.

United Way
  • Employees, friends and family donated supplies and funds to help our neighbors impacted by the May 16 tornado in St. Louis, MO. In addition, Essence matched donated funds to present United Way with a check for $100,000 in July. Employees volunteered in the cleanup effort as well.
Aging Ahead
  • Sponsoring meals and distribution for older adults in the Greater St. Louis area July through December.
Oasis
  • Sponsoring classes and a community fair.
    • Tai chi and Matter of Balance classes held at various locations in the Greater St. Louis area August through November.
    • Falls Prevention & Technology Fair September 25. This event at the Oasis Institute is free and open to the public. Attendees will receive resources and education about reducing fall risk and improving technology skills.
  •  

2025 Regulatory Guidance Alert

CMS notified health plans of a scheme to obtain patient records through fax requests. These faxes are being sent pretending to be CMS or the National Archives and Records Administration (NARA) and are often requesting records within a 72-hour deadline threatening termination from Medicare. CMS reminds providers that their requests will identify specific patients, time periods and encounters and provide ample time for response (30-45 days).

If you receive a suspicious request, please contact CMS, your Medicare Administrative Contractor (MAC), or Essence (if it involves one of our members) to verify its validity.

Cologuard Kits Mailed to Eligible Members

Essence Healthcare has partnered with Exact Sciences to mail Cologuard test kits directly to eligible members age 45 and older who are at average risk for colorectal cancer. The at-home test screens for both abnormal DNA and blood in stool, offering a convenient, noninvasive alternative to colonoscopy—at no cost to members.

Results are typically available within two weeks. If a patient tests positive, Exact Sciences will contact them to recommend follow-up with their healthcare provider for a colonoscopy. Providers will be notified of results if identified as the patient’s PCP.

See our flyer to learn more about the program and access additional resources.

online-white-on-blue

Visit the Provider Portal to:

  • View member information.
  • Check claim status.
  • Manage referrals and authorizations.
  • Access the Lumeris technology suite.
  • So much more.
Provider Portal

Need help creating a Provider Portal account? See instructions.

Want to know if a corrected claim is needed?

Follow our flow chart.

Programs to Support Claims Adjudication—Effective June 1, 2025

EXL for Post-Payment Reviews
We'll use ExlService.com, LLC (EXL) for post—payment reviews of outpatient claims concerning our Medicare Advantage plans. Acting as a subcontractor under Essence Healthcare, EXL is fully compliant with HIPAA and HITECH Act requirements, ensuring the confidentiality and security of PHI shared for auditing purposes.

ED Outpatient Facility Reimbursement with Optum ED Claim Analyzer
We've made revisions to the Emergency Department (ED) outpatient facility Evaluation and Management (E/M) coding reimbursement for all plans. We will employ the Optum Emergency Department Claim (EDC) Analyzer tool, which evaluates appropriate E/M coding levels based on claim data elements such as the:

  • Patient’s presenting problem
  • Diagnostic services performed
  • Patient complicating conditions
 
Log in to your Provider Portal to access all the resources below.

Search for Referrals/Authorizations

Click on the “Referral and Authorization Inquiry” tab to use our search tool. You can search by referral or authorization number, or by member ID.

Create and Edit a Referral

For detailed instructions on how to create, edit or print an existing referral review the Referral Guide on the Referrals & Authorizations page.

Prior Authorizations

The Referrals & Authorizations page also includes helpful lists for our HMO and PPO plans to help you determine when a service requires prior authorization.

Improvements—Survey Feedback

  • Provider staff can request prior authorization directly through our Provider Portal.
  • Coming soon: Real-time authorization responses for eligible services.
  • Empowered medical office staff through technology training to improve patient care.

For questions about these improvements, please send an email to providerservices@lumeris.com.

If you disagree with the amount Essence has paid on a claim or line, a provider dispute can be submitted in writing or through the Provider Portal. We don't accept fax submissions.

Send written pay disputes to:

Essence Correspondence or Claim
P.O. Box 5907
Troy, MI 48007

To submit your pay dispute electronically, log in to the Provider Portal and navigate to the Claims tab. Scroll to the bottom and complete the Provider Pay Dispute form.

Submitting Prescription Orders or Forms

Mail-Order

To submit Part D prescription drug orders, call Express Scripts mail-order pharmacy provider services at 1-888-327-9791. Direct Essence members to log in to their Essence Member Website to access the Express Scripts member portal.

Part D Determination/Exception

Submit forms to Express Scripts.
Fax: 1-877-251-5896
Phone: 1-800-935-6103
Call Essence Customer Service at 1-866-597-9560 to request a Part D coverage determination.

Real-Time Prescription Benefit Tool

Use the Real-Time Prescription Benefit Tool to check 2025 Part D formulary coverage and any applicable formulary Utilization Management requirements. This tool displays out-of-pocket drug cost estimates in the EMR to help the physician and patient decide on the best medication based on both medical necessity and cost-effectiveness.

To check provider credentialing status, please find your area in the list below and send an email.

Arkansas: littlerockcred@essencehealthcare.com

Kentucky: loulexcred@essencehealthcare.com

Missouri/Illinois: stlouiscred@essencehealthcare.com

Chicago: chicagocred@essencehealthcare.com

Ohio: cincinnaticred@essencehealthcare.com

MEMBER RESOURCES
BENEFITS

Benefit Information and Updates

Flexible Benefits Card: Medical copay coverage, OTC and More

What’s changed?
  • Medical copay coverage now possible via Flex Card (most plans).
  • Comprehensive dental covered primarily through Flex Card; no longer an embedded benefit on most plans.
  • OTC benefit removed from PPO plans and functions differently than in 2024 (see “How does the Flex Card Work?” section below). OTC is not available in Chicago.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Members can check benefits by logging in to EverythingEssence.com.

Many Essence plans now offer the ability to use the Flex Card for certain medical copays.

Accepted Medicare-covered copay categories:

  • Doctor/provider visits (including telehealth, occupational, speech and physical therapy, substance abuse, mental health sessions, podiatry)
  • Urgent care
  • Diagnostic services (such as labs, X‑rays, CT scans, MRIs and therapeutic radiology)
  • Dental, eye exam, acupuncture and chiropractic visits

Declined Charges

For Flex Card use on medical copays, the card must be eligible and used for services in an accepted copay category (shown above). If the card has this benefit and is being declined, the member’s balance could be low. Members can check their card balance on the Essence Flex Spend app or on the Member Website.

Depending on the plan, Flex Cards can be used for non-Medicare-covered dental, vision and hearing items and services, medical copays and/or OTC items. Not all categories apply to all plans.

The allowance for dental, vision, hearing and medical copays (if applicable) is loaded annually at the start of membership.

Members in plans that include the OTC benefit will receive a quarterly allowance that’s separate from the allowance for other Flex Card categories (if available in their plan), but members will use the same Flex Card for all allowed categories. The OTC allowance is valid at eligible physical retail locations or the online Essence OTC store.

The Flex Card may be used with in- or out-of-network providers. HMO plan members using the card for medical copays must stay in the Essence network.

Oura Ring and Data Sharing

Select PPO members are eligible to receive a free Oura Ring as part of their plan benefits. This wearable health tracker provides real-time, reliable insights into key health metrics, like sleep quality, activity level, heart rate, average blood oxygen and more.

We’re encouraging members to share this data with their providers. Oura Ring data can help you assess wellness trends, identify health issues, develop intervention strategies and—overall—provide more personalized, proactive care for your patients.

Essence is working with Oura to automate data sharing and deliver it to you electronically. We will be communicating with you once this functionality is available.

  • The Oura Ring is the only research-validated wearable in market that directly measures from the arteries in your fingers.
  • Oura measures resting heart rate at 99.9% reliability compared to a medical-grade ECG and validated against the sleep lab golden standard—PSG.
  • Oura measures heart rate variability at 98.4% reliability compared to medical-grade ECG.
  • Oura’s temperature sensors match performance with research-grade sensors at >99 percent and are able to detect baseline deviations as small as 0.13 degrees Celsius.
  • Oura’s infrared PPG sensor matched performance with clinical-grade ECG and consistently outperformed other PPG tools relying on green light LEDs or the iPhone camera.
  • Oura’s new sleep staging algorithm was found to achieve 79 percent agreement with gold-standard PSG for 4-stage sleep classification (wake, light, deep, and rapid eye movement (REM) sleep).

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Eligible members can learn more about this benefit by visiting EverythingEssence.com/s/OuraRing.

Vision Partner: EyeMed®

We partner with EyeMed®—a leader in vision benefits, focusing on choice, convenience and savings. Members can find in-network providers by calling EyeMed at 1-833-918-0475 or visiting EyeDocLocator.EyeMedVisionCare.com/Essence/en-us.

Providers can see a list of vision providers by using our online search tool.

All plans, except Essence Advantage® Premier Plus (PPO) include routine vision benefits and an eyewear allowance. Most plans also include a preloaded Flex Card that can be used on vision services and eyewear.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Eligible members can learn more about this benefit by logging in to EverythingEssence.com.

Prescription Drug Coverage

What’s changed:
  • No more Donut Hole, plus lower Part D out-of-pocket maximum
  • Most Essence plans now require a Part D deductible on tiers 3-5
  • New pharmacy benefit manager and mail-order pharmacy: Express Scripts
  • Expanded preferred pharmacy network
  • Preferred brand diabetic blood glucose meters for all plans now Abbott and LifeScan brand products
  • Changes to covered insulins

Initial coverage: Members pay $0 for preferred generics at preferred pharmacies and by mail order, and low copays for brand-name drugs.

Part D out-of-pocket max (end of initial coverage phase): $2,000

Catastrophic coverage: Members pay $0 for all covered Part D drugs

Members must meet their Part D deductible (if applicable) before standard cost-sharing applies.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Members can learn more about this benefit by logging in to EverythingEssence.com.

Essence now partners with Express Scripts® for prescription drug benefits, including mail-order benefits.

New mail-order prescriptions should be sent to Express Scripts mail-order pharmacy. You can contact Express Scripts by phone: 1-888-327-9791.

Starting June 15, 2025, Evernorth EnGuideSM Pharmacy will be the new home delivery pharmacy for GLP-1 medications.

  • Current patients using mail-order through Express Scripts™ Pharmacy to fill GLP-1 medications will receive communications about the change from Express Scripts beginning June 2.
  • Patients can continue to fill GLP-1 medications at any in-network pharmacy.
  • GLP-1 medication prescriptions currently filled through mail order, including any remaining refills, will automatically transfer to EnGuide Pharmacy by June 15.
  • If no refills are available, EnGuide Pharmacy will contact the provider for a new prescription.
  • Express Scripts will notify high-volume prescribers (5+ GLP-1 scripts) about this change.
  • Non-GLP-1 medications will continue to be filled by Express Scripts Pharmacy for home delivery.

Preferred pharmacies include CVS, Sam‘s Club, Walmart and many others.

For a complete list of preferred pharmacies, use our online search tool. Members can view their plan’s provider directory on EverythingEssence.com.

Essence members can visit the “Pharmacy” section of EverythingEssence.com for a direct link to the Express Scripts member portal (for claims information, mail-order signup, formulary and more).

Preferred-brand diabetic blood glucose meters and test strips are Abbott and LifeScan brand products.

Members can learn how to get a new preferred-brand glucose meter or test strips free of charge by visiting the “Pharmacy” section of EverythingEssence.com. Once on the pharmacy page, members will click “Diabetic Testing Supplies at Network Pharmacies.” You can access this form here.

Certain insulins were removed from our formulary starting January 1, 2025. If none of the formulary insulin alternatives listed below are right for your patient, they, or you, can submit an exception request to our formulary. Refer Essence members to Chapter 5 of their Evidence of Coverage (“Using the plan’s coverage for Part D prescription drugs”) for more information.

You can also submit a Part D determination/exception request on your patient’s behalf. Download the form here. Submit forms to Express Scripts by phone at 1-800-935-6103 or by fax at 1-877-251-5896.

2024 Insulins (not covered in 2025 formulary) 2025 Formulary Insulin Alternatives
insulin aspart and Fiasp insulin insulin lispro, Humalog (vials and KwikPen)
aspart protamine insulin Humalog mix (KwikPen and vials)
Semglee Lantus and Toujeo insulins
Novolin 70/30, N and R insulins (vial and Flexpen) Humulin 70/30, Humulin N and R insulins (vials and KwikPen)

Flexible Benefits Card: Medical copay coverage, OTC and More

What’s changed?
  • Medical copay coverage now possible via Flex Card (most plans).
  • Comprehensive dental covered primarily through Flex Card; no longer an embedded benefit on most plans.
  • OTC benefit removed from PPO plans and functions differently than in 2024 (see “How does the Flex Card Work?” section below). OTC is not available in Chicago.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Members can check benefits by logging in to EverythingEssence.com.

Many Essence plans now offer the ability to use the Flex Card for certain medical copays.

Accepted Medicare-covered copay categories:

  • Doctor/provider visits (including telehealth, occupational, speech and physical therapy, substance abuse, mental health sessions, podiatry)
  • Urgent care
  • Diagnostic services (such as labs, X‑rays, CT scans, MRIs and therapeutic radiology)
  • Dental, eye exam, acupuncture and chiropractic visits

Declined Charges

For Flex Card use on medical copays, the card must be eligible and used for services in an accepted copay category (shown above). If the card has this benefit and is being declined, the member’s balance could be low. Members can check their card balance on the Essence Flex Spend app or on the Member Website.

Depending on the plan, Flex Cards can be used for non-Medicare-covered dental, vision and hearing items and services, medical copays and/or OTC items. Not all categories apply to all plans.

The allowance for dental, vision, hearing and medical copays (if applicable) is loaded annually at the start of membership.

Members in plans that include the OTC benefit will receive a quarterly allowance that’s separate from the allowance for other Flex Card categories (if available in their plan), but members will use the same Flex Card for all allowed categories. The OTC allowance is valid at eligible physical retail locations or the online Essence OTC store.

The Flex Card may be used with in- or out-of-network providers. HMO plan members using the card for medical copays must stay in the Essence network.

Oura Ring and Data Sharing

Select PPO members are eligible to receive a free Oura Ring as part of their plan benefits. This wearable health tracker provides real-time, reliable insights into key health metrics, like sleep quality, activity level, heart rate, average blood oxygen and more.

We’re encouraging members to share this data with their providers. Oura Ring data can help you assess wellness trends, identify health issues, develop intervention strategies and—overall—provide more personalized, proactive care for your patients.

Essence is working with Oura to automate data sharing and deliver it to you electronically. We will be communicating with you once this functionality is available.

  • The Oura Ring is the only research-validated wearable in market that directly measures from the arteries in your fingers.
  • Oura measures resting heart rate at 99.9% reliability compared to a medical-grade ECG and validated against the sleep lab golden standard—PSG.
  • Oura measures heart rate variability at 98.4% reliability compared to medical-grade ECG.
  • Oura’s temperature sensors match performance with research-grade sensors at >99 percent and are able to detect baseline deviations as small as 0.13 degrees Celsius.
  • Oura’s infrared PPG sensor matched performance with clinical-grade ECG and consistently outperformed other PPG tools relying on green light LEDs or the iPhone camera.
  • Oura’s new sleep staging algorithm was found to achieve 79 percent agreement with gold-standard PSG for 4-stage sleep classification (wake, light, deep, and rapid eye movement (REM) sleep).

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Eligible members can learn more about this benefit by visiting EverythingEssence.com/s/OuraRing.

Vision Partner: EyeMed®

We partner with EyeMed®—a leader in vision benefits, focusing on choice, convenience and savings. Members can find in-network providers by calling EyeMed at 1-833-918-0475 or visiting EyeDocLocator.EyeMedVisionCare.com/Essence/en-us.

Providers can see a list of vision providers by using our online search tool.

All plans, except Essence Advantage® Premier Plus (PPO) include routine vision benefits and an eyewear allowance. Most plans also include a preloaded Flex Card that can be used on vision services and eyewear.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Eligible members can learn more about this benefit by logging in to EverythingEssence.com.

Prescription Drug Coverage

What’s changed:
  • No more Donut Hole, plus lower Part D out-of-pocket maximum
  • Most Essence plans now require a Part D deductible on tiers 3-5
  • New pharmacy benefit manager and mail-order pharmacy: Express Scripts
  • Expanded preferred pharmacy network
  • Preferred brand diabetic blood glucose meters for all plans now Abbott and LifeScan brand products
  • Changes to covered insulins

Initial coverage: Members pay $0 for preferred generics at preferred pharmacies and by mail order, and low copays for brand-name drugs.

Part D out-of-pocket max (end of initial coverage phase): $2,000

Catastrophic coverage: Members pay $0 for all covered Part D drugs

Members must meet their Part D deductible (if applicable) before standard cost-sharing applies.

For member-specific benefits, visit the “Eligibility” section of your Provider Portal. Members can learn more about this benefit by logging in to EverythingEssence.com.

Essence now partners with Express Scripts® for prescription drug benefits, including mail-order benefits.

New mail-order prescriptions should be sent to Express Scripts mail-order pharmacy. You can contact Express Scripts by phone: 1-888-327-9791.

Starting June 15, 2025, Evernorth EnGuideSM Pharmacy will be the new home delivery pharmacy for GLP-1 medications.

  • Current patients using mail-order through Express Scripts™ Pharmacy to fill GLP-1 medications will receive communications about the change from Express Scripts beginning June 2.
  • Patients can continue to fill GLP-1 medications at any in-network pharmacy.
  • GLP-1 medication prescriptions currently filled through mail order, including any remaining refills, will automatically transfer to EnGuide Pharmacy by June 15.
  • If no refills are available, EnGuide Pharmacy will contact the provider for a new prescription.
  • Express Scripts will notify high-volume prescribers (5+ GLP-1 scripts) about this change.
  • Non-GLP-1 medications will continue to be filled by Express Scripts Pharmacy for home delivery.

Preferred pharmacies include CVS, Sam‘s Club, Walmart and many others.

For a complete list of preferred pharmacies, use our online search tool. Members can view their plan’s provider directory on EverythingEssence.com.

Essence members can visit the “Pharmacy” section of EverythingEssence.com for a direct link to the Express Scripts member portal (for claims information, mail-order signup, formulary and more).

Preferred-brand diabetic blood glucose meters and test strips are Abbott and LifeScan brand products.

Members can learn how to get a new preferred-brand glucose meter or test strips free of charge by visiting the “Pharmacy” section of EverythingEssence.com. Once on the pharmacy page, members will click “Diabetic Testing Supplies at Network Pharmacies.” You can access this form here.

Certain insulins were removed from our formulary starting January 1, 2025. If none of the formulary insulin alternatives listed below are right for your patient, they, or you, can submit an exception request to our formulary. Refer Essence members to Chapter 5 of their Evidence of Coverage (“Using the plan’s coverage for Part D prescription drugs”) for more information.

You can also submit a Part D determination/exception request on your patient’s behalf. Download the form here. Submit forms to Express Scripts by phone at 1-800-935-6103 or by fax at 1-877-251-5896.

2024 Insulins (not covered in 2025 formulary) 2025 Formulary Insulin Alternatives
insulin aspart and Fiasp insulin insulin lispro, Humalog (vials and KwikPen)
aspart protamine insulin Humalog mix (KwikPen and vials)
Semglee Lantus and Toujeo insulins
Novolin 70/30, N and R insulins (vial and Flexpen) Humulin 70/30, Humulin N and R insulins (vials and KwikPen)
MARK YOUR CALENDAR
September 17, 2025 MO/IL
Provider Expo

9 a.m. - 5 p.m., Central Time
3251 Riverport Ln., St. Louis, MO 63043

September 25, 2025 MO/IL
Falls Prevention & Technology Fair

11 a.m. - 2 p.m., Central Time
Oasis Institute
500 Northwest Plaza, St. Ann, MO 63074

REGULATORY CHANGES
April 1, 2025
The Qualified Medicare Beneficiary (QMB) Program
All Medicare providers, even those that do not accept Medicaid, are prohibited under federal law from billing members in the QMB Program for their cost-share of covered Parts A and B services, including Part B-covered prescription drugs, and are prohibited from discriminating against QMBs by refusing service because of this cost-share protection. Essence encourages providers to establish processes to routinely identify the QMB status of members. Essence offers several options to help identify QMB status:
  • Contact the Plan’s customer service team
  • Review the member profile on the Provider Portal
  • Submit a 270-transaction set to inquire about Medicare eligibility. Medicare providers can seek payment for Medicare cost-sharing for QMB-eligible members from the member’s state Medicaid program. Please consult the applicable state Medicaid program for information on billing processes that apply to seeking payment from Medicaid.
 
April 30, 2025
Balance Billing
In accordance with CMS rules, as an Essence network provider, network providers are not permitted to balance bill Essence members. The term “balance billing” refers to billing a member for more than the plan-allowed cost-sharing for a covered service or billing a member for a covered service Essence denied. The Essence member is held harmless for payment beyond the Essence cost-share (copayment or coinsurance). The provider’s remit notice indicates whether an amount is owed by the member and that’s what the provider should follow when billing the member. If a member qualifies for state assistance you may see codes on your remittance notice which limit the ability to balance bill.
 
FREQUENTLY ASKED QUESTIONS

When a member disagrees with a decision made by their health plan regarding the services or benefits covered under Part C or Part D, they can appeal. The member has the right to ask for this decision to be reviewed if they think it's wrong. This can include if the health plan is taking too long to approve or arrange the care or drugs needed, or if the member thinks they should pay less for a service or drug.

Contracted providers have the right to a pay dispute rather than an appeal. If you disagree with the amount Essence has paid on a claim or line a provider dispute can be submitted in writing or through the Provider Portal. We don’t accept fax submissions.

Send written pay disputes to:
Essence Correspondence or Claim
P.O. Box 5907
Troy, MI 48007

To submit your pay dispute electronically, log in to the Provider Portal and navigate to the Claims tab. Scroll to the bottom and complete the Provider Pay Dispute form.

Many Essence plans offer the ability to use the Flex Card for certain medical copays.

Accepted Medicare-covered copay categories:

  • Doctor/provider visits (including telehealth, occupational, speech and physical therapy, substance abuse, mental health sessions, podiatry)
  • Urgent care
  • Diagnostic services (such as labs, X-rays, CT scans, MRIs and therapeutic radiology)
  • Dental, eye exam, acupuncture and chiropractic visits

Declined Charges

For Flex Card use on medical copays, the card must be eligible and used for services in an accepted copay category (see above list). If the card has this benefit and is declined, the member’s balance could be low. Members can check their card balance on the Essence Flex Spend app or on the Member Website (EverythingEssence.com).

For more information on the Flex Card, see the “Benefit Information and Updates” section on this page.

Mail-Order

Pharmacy provider services

Phone: 1-888-327-9791

Part D Determination/Exception

Submit forms to Express Scripts.

Fax: 1-877-251-5896

Phone: 1-800-935-6103

Essence members can call Express Scripts at 1-800-282-2881 (TTY: 1-800-759-1089) to get help with their prescriptions.

For general provider questions or to get more information about an event send an email to: providerservices@lumeris.com.

If you're in the Chicago area, please send an email to: chicagomarket@lumeris.com.