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Essence · PDF fileProvider Directory 1 Essence Advantage (HMO) Provider DirectoryProvider Directory Provider Directory This directory provides a list of Essence’s network

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  • Provider Directory

    1

    EssenceEssenceEssenceEssence AdvantageAdvantageAdvantageAdvantage (HMO)(HMO)(HMO)(HMO) Provider DirectoryProvider DirectoryProvider DirectoryProvider Directory

    Provider Directory

    This directory provides a list of Essences network providers.

    This directory is for the MO/IL Service area. It includes Boone, Jefferson, Saint Charles, Saint Francois, Saint Louis City and Saint Louis Counties in MO; Madison, Monroe and Saint Clair Counties in IL.

    This directory is current as of August 2015. Some network providers may have been added or removed from our network after this directory was printed. We do not guarantee that each provider is still accepting new members. To get the most up-to-date information about Essences network providers in your area, you can visit www.everythingessence.com or call our Customer Service Department at (314) 209-2700 or toll free (866) 597-9560, 7 days a week from 8:00 a.m. to 8:00 p.m. You may receive a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day. TTY users should call 711.

    Essence is a Medicare Advantage organization with a Medicare contract. Enrollment in Essence depends on contract renewal.

    We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-866-597-9560. Someone who speaks English can help you. This is a free service.

    This information may be available in a different format, including Braille, large print or audio. Please call Customer Service at the number listed above if you need plan information in another format or language.

    The pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

    Y0027_15-051_EN CMS Accepted 09/07/2015

  • Provider Directory

    *Providers who also accept Medicaid Preferred Pharmacy Extended Day Supply Pharmacies 2

  • Provider Directory

    *Providers who also accept Medicaid Preferred Pharmacy Extended Day Supply Pharmacies 3

    IntroductionIntroductionIntroductionIntroduction

    This directory provides a list of Essences network providers. To get detailed information about your health care coverage, please see your Evidence of Coverage.

    You will have to choose one of our network providers who are listed in this directory to be your PPPPrimary CCCCare PPPPhysician (PCP). The term PCP will be used throughout this directory. Generally, you must get your health care services from your PCP. The network providers listed in this directory have agreed to provide you with your health care/vision/dental services. You may go to any of our network providers listed in this directory; however, some services may require a referral. If you have been going to one network provider, you are not required to continue to go to that same provider. In some cases, you may get covered services from non-network providers. Providers identified with an asterisk (*) also accept Medicaid.Providers identified with an asterisk (*) also accept Medicaid.Providers identified with an asterisk (*) also accept Medicaid.Providers identified with an asterisk (*) also accept Medicaid. The name and phone number of your PCP is printed on your membership ID card.

    You will get your routine or basic care from yYou will get your routine or basic care from yYou will get your routine or basic care from yYou will get your routine or basic care from your PCP.our PCP.our PCP.our PCP. Your PCP will coordinate the rest of the covered services you need. This includes x-rays, laboratory tests, therapies, specialist visits, hospital admissions, and follow-up care. Your PCP also contacts other network providers for updates about your care and/or treatment. If you need certain types of covered services or supplies, your PCP must give approval ahead of time.

    Your PCP must give you a referral to see a specialistYour PCP must give you a referral to see a specialistYour PCP must give you a referral to see a specialistYour PCP must give you a referral to see a specialist. When your PCP thinks you need specialized treatment, he or she will give you a referral (approval ahead of time) to see a network specialist. A specialistspecialistspecialistspecialist is a doctor who provides health care services for a specific disease or part of the body. If you want to use a particular Essence specialist or hospital, you should check with your PCP to make sure he/she can make referrals to that specialist or hospital.

    It is very important to get a referral from your PCP beforebeforebeforebefore you see a network specialist. If you do not have a If you do not have a If you do not have a If you do not have a referral before you get services from a specialist,referral before you get services from a specialist,referral before you get services from a specialist,referral before you get services from a specialist, you may have to pay for these services yourself. you may have to pay for these services yourself. you may have to pay for these services yourself. you may have to pay for these services yourself. If the specialist wants you to come back for follow-up visits, be sure to check the original referral to see if these were included.

    In some cases, your PCP will need to get prior authorization from EssencIn some cases, your PCP will need to get prior authorization from EssencIn some cases, your PCP will need to get prior authorization from EssencIn some cases, your PCP will need to get prior authorization from Essence.e.e.e. A prior authorization is an approval from the plan for medical services and must be requested beforebeforebeforebefore services are received. Since your PCP will provide and coordinate your health care, you should have all of your past medical records sent to your new PCPs office. The law requires us to protect the privacy of your medical records and personal health information. For more information about privacy, see your Evidence of Coverage.

    You may change your PCP for any reason, at any time.You may change your PCP for any reason, at any time.You may change your PCP for any reason, at any time.You may change your PCP for any reason, at any time. To change your PCP, call our Customer Service Department. PCP changes take effect the first day of the following monthPCP changes take effect the first day of the following monthPCP changes take effect the first day of the following monthPCP changes take effect the first day of the following month. RRRRequests for equests for equests for equests for retroactive retroactive retroactive retroactive changes changes changes changes are typically not approved.are typically not approved.are typically not approved.are typically not approved. When you call, be sure to let Customer Service know if you are seeing specialists or getting other covered services that needed your PCPs approval (such as home health services and durable medical equipment). Customer Service will change your membership record to show the name of your new PCP. They will also send you an updated membership card with the name and phone number of your new PCP.

    Some services you may get on your own.Some services you may get on your own.Some services you may get on your own.Some services you may get on your own. There are only a few types of covered services you can get without seeing your PCP first. SelfSelfSelfSelf----referredreferredreferredreferred means you get service on your own. If you get self-referred services, you still have to pay a co-payment. If you get a self-referred service from a network provider, you will only have to pay the in-network co-payment. If you go to an out-of-network provider for these services, you will have to pay more.

  • Provider Directory

    *Providers who also accept Medicaid Preferred Pharmacy Extended Day Supply Pharmacies 4

    The following services may be selfThe following services may be selfThe following services may be selfThe following services may be self----referred:referred:referred:referred:

    Routine eye exams an annual exam for the purposes of determining changes to your vision and the possible need for eyeglasses or contact lenses. Please see the Routine Vision Care Provider section Please see the Routine Vision Care Provider section Please see the Routine Vision Care Provider section Please see the Routine Vision Care Provider section at the end of this directory for a list of network providers you may use without a referral.at the end of this directory for a list of network providers you may use without a referral.at the end of this directory for a list of network providers you may use without a referral.at the end of this directory for a list of network providers you may use without a referral.

    Routine womens health care, which includes breast exams, mammograms (x-rays of the breast), pap tests, and pelvic exams. This care is covered without a referral from your PCP only if you get it from a network provider.

    Flu shots and pneumonia vaccinations (only if you get them from a network provider).

    Emergency services, whether you get these services from network providers or out-of-network providers. The emergency Services, Inc.luding hospital care after you are stable (known as post-stabilization) are also covered.

    Urgently needed care you receive from out-of-network providers when you are temporarily outside the plans service area.

    Renal dialysis (kidney) services that you get when you are temporarily outside the plans service area. If possible, please let us know before you leave the service area and where you will be. We can help ar