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Essence Healthcare - Provider Directory - Provider Pharmacy Directory EssenceESSENCE ADVANTAGE® (HMO) • ESSENCE ADVANTAGE PLUS® (HMO) ESSENCE ADVANTAGE SELECT® (HMO) • ESSENCE DUAL ADVANTAGE (HMO D-SNP)
Essence Advantage and Essence Advantage Select serve St. Louis city, the Missouri counties of Jefferson, St. Charles, St. Louis, and the Illinois counties of Madison, Monroe and St. Clair
Essence Advantage serves the Missouri county of Boone
Essence Dual Advantage serves St. Louis city and the Missouri counties of Jefferson, St. Charles and St. Louis
This Provider/Pharmacy Directory was updated on 02/02/2022. For more recent information or other questions, please contact Essence Healthcare Customer Service at 1-866-597-9560 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week. You may reach a messaging service on weekends from April 1 through September 30 and holidays. Please leave a message, and your call will be returned the next business day.
Changes to our Provider/Pharmacy Directory may occur during the benefit year. An updated Provider/Pharmacy Directory is located on our website at www.EssenceHealthcare.com. You may also call Customer Service for updated provider information.
Provider Directory Provider Directory
This directory is current as of February 2, 2022. This directory provides a list of Essence Advantage’s current network providers. This directory is for the Missouri/Illinois Service area. It includes Boone, Jefferson, Saint Charles, and Saint Louis Counties, and Saint Louis City in Missouri; Madison, Monroe and Saint Clair counties in Illinois. To access Essence Advantage’s online provider directory, you can visit www.everythingessence.com. For any questions about the information contained in this directory (hardcopy or online), please call our Customer Service Department at 314-209-2700 or toll free 1-866-597-9560, seven days a week from 8 a.m. to 8 p.m. 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. To request a hard copy of Essence Advantage’s provider directory, please call our Customer Service Department at 314-209-2700 or toll free 1-866-597-9560, seven days a week from 8 a.m. to 8 p.m. Essence Advantage will mail a hard copy of the provider directory to you within three (3) business days of your request. Essence Advantage may ask whether your request for a hard copy is a one-time request or if you are requesting to receive the provider directory in hard copy permanently. If you request it, your request for hard copies of the provider directory remains until you leave Essence Advantage or request that hard copies be discontinued. Essence Healthcare includes HMO plans with a Medicare contract. Essence Healthcare also includes an HMO D-SNP plan with a contract with Medicare and the state of Missouri Medicaid program. Enrollment in Essence Healthcare 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, call us at 1-866-597-9560. Your call will be answered by someone who speaks English, who will help connect you to an interpreter for your language. This is a free service. This information may be available in a different format, including Braille, large print. 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.
Section 2 - List of Network Providers ..................................................................................... 10 Hospitals ........................................................................................................................................................................... 10
Hospitals (23) ................................................................................................................................................... 10 Primary Care Physicians .............................................................................................................................................. 12
Primary Care Physicians (521).................................................................................................................... 12 Specialty Care Providers ............................................................................................................................................. 60
Allergy & Immunology (50) ........................................................................................................................ 60 Cardiothoracic Surgery (43) ....................................................................................................................... 64 Cardiovascular Disease (273) ..................................................................................................................... 68 Chiropractic (82) ............................................................................................................................................. 95 Colorectal Surgery (29) ............................................................................................................................. 101 Dermatology (125) ...................................................................................................................................... 103 Dermatology Mohs (6) .............................................................................................................................. 116 Dietician (17) ................................................................................................................................................. 116 Electrophysiology (33) ............................................................................................................................... 118 Endocrinology (85) ..................................................................................................................................... 121 Female Pelvic Medicine and Reconstruction (16) ........................................................................... 129 Gastroenterology (177) ............................................................................................................................. 130 General Surgery (163) ................................................................................................................................ 147 Gynecological Oncology (25) ................................................................................................................. 161 Hand Surgery (22) ....................................................................................................................................... 164 Hematology (67) .......................................................................................................................................... 166 Infectious Disease (64) .............................................................................................................................. 172 Interventional Cardiology (69) ............................................................................................................... 178 Interventional Radiology (8) .................................................................................................................... 185 Nephrology (130) ........................................................................................................................................ 186 Neurological Surgery (80) ........................................................................................................................ 198 Neurology (160) ........................................................................................................................................... 205 Neuropsychology (6) ................................................................................................................................. 219 Neuroradiology (1) ..................................................................................................................................... 220 Neurotology (3) ........................................................................................................................................... 220 OBGYN - Gyn Only (2) ............................................................................................................................... 221 Obstetrics / Gynecology (317) ................................................................................................................ 221 Oncology (161)............................................................................................................................................. 250 Ophthalmology (207) ................................................................................................................................ 263 Ophthalmology - Corneal (13) ............................................................................................................... 283
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Ophthalmology-Retina Only (42) .......................................................................................................... 284 Optometrist (488) ........................................................................................................................................ 288 Oral and Maxillofacial Surgery (1) ......................................................................................................... 330 Orthopedic Surgery (307) ........................................................................................................................ 331 Otolaryngology (ENT) (122) .................................................................................................................... 362 Pain Management (68) .............................................................................................................................. 374 Palliative Medicine (8) ............................................................................................................................... 381 Phlebology (1) .............................................................................................................................................. 382 Physical Medicine & Rehabilitation (45) ............................................................................................. 382 Plastic & Reconstructive Surgery (51) ................................................................................................. 387 Podiatry (156) ............................................................................................................................................... 391 Pulmonary Disease (133) .......................................................................................................................... 406 Radiation Oncology (73) ........................................................................................................................... 418 Radiology (38) .............................................................................................................................................. 425 Rheumatology (56) ..................................................................................................................................... 428 Sleep Medicine (23) .................................................................................................................................... 433 Spine Surgery (1) ......................................................................................................................................... 435 Sports Medicine (24) .................................................................................................................................. 435 Surgical Oncology (19) .............................................................................................................................. 438 Thoracic Surgery (15) ................................................................................................................................. 439 Urology (128) ................................................................................................................................................ 441 Vascular Surgery (57) ................................................................................................................................. 454 Wound Care (7) ............................................................................................................................................ 459
Other Contracted Providers ................................................................................................................................... 461 Ambulatory Surgical Center (48) ........................................................................................................... 461 Audiology (77) .............................................................................................................................................. 464 Dialysis Center (73) ..................................................................................................................................... 469 Durable Medical Equipment (45) .......................................................................................................... 473 Free Standing Radiology (23) ................................................................................................................. 476 Home Health Agency (26) ........................................................................................................................ 477 Home Infusion Therapy (8) ...................................................................................................................... 479 Independent Lab (16) ................................................................................................................................ 479 Long Term Care Facility (5) ...................................................................................................................... 480 Orthotics and Prosthetics (17) ................................................................................................................ 480 Portable X-ray Suppliers (3) .................................................................................................................... 481 Rehabilitation Hospital (9) ....................................................................................................................... 481 Skilled Nursing Facility (63) ..................................................................................................................... 482 Sleep Lab (4) .................................................................................................................................................. 486 Therapy - Occupational (32) ................................................................................................................... 486 Therapy - Physical (211)............................................................................................................................ 489 Therapy - Speech (17) ............................................................................................................................... 508 Transportation (1) ....................................................................................................................................... 509 Urgent Care Center (26)............................................................................................................................ 509
Mental Health, Chemical Dependency and Substance Abuse Providers .............................................. 513 Facilities Mental Health - Outpatient (17) ........................................................................................ 513
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Facilities Mental Health - Inpatient (12) ............................................................................................. 514 Facilities Substance Abuse - Inpatient (9) .......................................................................................... 515 Facilities Substance Abuse - Outpatient (18) .................................................................................... 515 Certified Nurse Specialist (1) ................................................................................................................... 516 Licensed Clinical Social Worker (185) .................................................................................................. 517 Licensed Marriage and Family Therapist (1) ..................................................................................... 529 Licensed Professional Counselor (157) ............................................................................................... 529 Psychiatry (202) ............................................................................................................................................ 539 Psychology (56) ............................................................................................................................................ 557
Dental Care Providers ............................................................................................................................................... 562 Dental Health (1) ......................................................................................................................................... 562
Routine Vision Care Providers ............................................................................................................................... 563 Routine Vision (1) ........................................................................................................................................ 563
Pharmacy Directory ................................................................................................................................................... 564 Retail Pharmacies including Chain Pharmacies (192) .................................................................... 565 Mail Order Pharmacy ................................................................................................................................. 576 Mail Order Pharmacies (1) ....................................................................................................................... 576 Home Infusion Pharmacies ...................................................................................................................... 577 Home Infusion (9) ....................................................................................................................................... 577 Long Term Care Pharmacies ................................................................................................................... 578 Long Term Care (69) .................................................................................................................................. 578
Alphabetical Physician Index ................................................................................................................................. 583
Section 1 - Introduction
Section 1 - Introduction This directory provides a list of Essence Advantage network providers. To get detailed information about your healthcare coverage, please see your Evidence of Coverage (EOC). You will have to choose one of our network providers listed in this directory to be your Primary Care Physician (PCP). Generally, you must get your healthcare services from your PCP. The name and telephone number of your PCP is printed on your membership ID card. The network providers listed in this directory have agreed to provide you with your healthcare, vision and 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. Please refer to your EOC for details. Providers identified with an asterisk (*) also accept Medicaid. The number following the 10-digit number listed below the provider’s name is the provider’s National Provider Identifier (NPI) number. In the Hospital section, the capital letters following the word “Code” show that hospital’s code. When a hospital’s code follows a provider’s information, it indicates to which hospital(s) that provider has privileges for admitting patients. You will get your routine or basic care from your 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 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 specialist is a doctor who provides healthcare services for a specific disease or part of the body. If you want to use a particular Essence Advantage 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 before you see a network specialist. If you do not have a referral before you get services from a specialist, 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 Essence Advantage. A prior authorization is an approval from the plan for medical services and must be requested before services are received. Since your PCP will provide and coordinate your healthcare, you should have all of your past medical records sent to your new PCP’s 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.
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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 month. Requests for retroactive changes are typically not approved. When you call, be sure to let the customer service representative know if you are seeing specialists or getting other covered services that needed your PCP’s approval (such as home health services and durable medical equipment). The customer service representative 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 telephone number of your new PCP. 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. “Self-referred” means you get service on your own. If you get self-referred services, you still have to pay a copayment. If you get a self-referred service from a network provider, you will only have to pay the in-network copayment. If you obtain routine care from out-of-network providers neither Medicare nor Essence Advantage will be responsible for the cost.
The following services may be self-referred:
• Routine eye exam – 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 at the end of this directory for information on how to find network providers that you may use without a referral from your PCP.
• Routine women’s healthcare – this 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 – these are covered only if you get them from a network provider.
• Emergency services – whether you get these services from network providers or out-of-network providers, emergency services including hospital care after you are stable (known as post- stabilization) are also covered.
• Urgently needed care – this includes care you receive from out-of-network providers when you are temporarily outside the plan’s service area.
• Renal dialysis – kidney services that you get when you are temporarily outside the plan’s service area are covered. If possible, please let us know before you leave the service area and where you will be. We can help arrange for you to have maintenance dialysis while you are away.
Getting care when traveling or are away from the plan’s service area. If you need medical care when you are outside the service area, your healthcare coverage is very limited. The only services we cover when you are outside our service area are care for a medical emergency, including maintenance care and hospital care after you are stable (known as post-stabilization care), urgently needed care, renal dialysis (kidney), and care that Essence Advantage has approved in advance. If you question whether a service is covered when you travel, please call our Customer Service Department.
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The difference between a medical emergency and urgently needed care is the seriousness of the condition.
• A medical emergency is when you believe your health is in serious danger - when every second counts. You may have a bad injury, sudden illness, or an illness that is quickly getting much worse.
• Urgently needed care is care you get for a sudden illness or injury that needs medical care right away, but is not life threatening. Treatment for a sprained ankle is an example of urgently needed care.
Your PCP generally provides urgently needed care. If you have a sudden illness or injury that is not a medical emergency and you are in the plan’s service area, please call your PCP. If the office is closed, there will always be a doctor on call to help you. Please note: If you have an urgent need for care while you are in the plan’s service area, you should get this care from network providers. In most cases, we will not pay for urgently needed care that you get from out-of-network providers while you are in the plan’s service area. If you are out of the plan’s service area and cannot wait until you return, Essence Advantage will pay for urgently needed care you receive from out-of-network providers. We will cover follow-up care that you get from out-of-network providers outside the plan’s service area if the care you receive still meets the urgently needed care definition. Once you return to the service area, your PCP will provide any needed follow-up care. If you have a medical emergency:
• Get medical help as quickly as possible. Call 911 for help or go directly to the nearest emergency room. In any emergency, you do not need permission (authorization) or a referral before getting medical assistance.
• Emergency medical care is covered whenever you need it, anywhere in the world. • Ambulance services are covered in situations where other means of transportation, anywhere in
the world, would endanger your health. • As soon as possible, you or someone else should contact your PCP about your emergency. Your
PCP’s telephone number is located on your membership ID card. Your PCP needs to know about your emergency because he/she will provide or arrange follow-up care. Please try to contact your PCP about your emergency within 48 hours.
Your PCP will help manage and follow-up on your emergency care. It is important to know that every emergency has two stages. When the doctors or hospital providing emergency care consider your condition stable the first stage of the medical emergency ends. However, even after your condition is stabilized, you are still considered in an emergency situation and Essence Advantage must pay for post-stabilization treatment provided by the hospital (whether or not this hospital is a network provider or not). The second stage of the emergency, after your condition is stabilized, is called post-stabilization. Generally, the hospital, or doctors, providing emergency care will try to talk to your PCP. This helps the plan arrange for network providers to take over your care as soon as your condition and circumstances get better. Once your PCP takes over your care or agrees with the attending hospital on an appropriate course of action (or once you are discharged, if you are fully recovered), you are no longer in an emergency or post- stabilization situation.
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When you are past the emergency and post-stabilization stages, you may still need follow-up care. Essence Advantage is responsible for your follow-up care. Essence Advantage will only pay for follow-up care (care provided after your emergency and post-stabilization stages) if you follow the plan rules. Your PCP can assist you with finding network providers and securing the appropriate referrals and authorizations. You should never pay any out-of-network provider more than what the provider is allowed by Medicare. The provider has a right to get his or her fees, but does not have a right to receive them from you. Ask the out- of-network provider to bill us first. If you have already paid for the covered services, we will reimburse you for our share of the cost. If you get a bill for the services, you can send the bill to us for payment. We will pay the out-of-network provider for our share of the bill if it meets the criteria noted above and will let you know what, if anything, you must pay. If an out-of-network provider asks you to pay for covered services you get in these situations, please call our Customer Service Department. While Essence Advantage does not contract with specialists who provide certain services at a healthcare facility (such as anesthesiologists and pathologists), we do pay the facility for the cost of these services when provided at an Essence Advantage contracted facility. If you receive a bill for such services, please contact Essence Advantage Customer Service. You must use network providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Essence Advantage will be responsible for the costs. What is the service area for Essence Advantage? The counties in our service area are listed below.
In Missouri – In Illinois – Boone County Madison County Jefferson County Monroe County St. Charles County St. Clair County St. Louis City St. Louis County
How do you find Essence Advantage providers in your area? This directory includes individual sections for our Network Hospitals, Primary Care Physicians, Specialists, Other Contracted Providers, Mental Health Providers, Routine Vision Care Providers and Pharmacies. Each section is organized first by state, then by county. An alphabetical index of physicians can be found at the end of the directory. If you have questions about Essence Advantage or require assistance in selecting a PCP, please call our Customer Service Department at 314-209-2700 or toll free 1-866-597-9560, seven days a week from 8 a.m. to 8 p.m. 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. You can also visit www.everythingessence.com.
10 *Providers who also accept Medicaid †Preferred Pharmacy ¥Extended Day Supply Pharmacies
Hospitals
Essence Advantage Hospitals
Hospitals (23) ILLINOIS Madison County, IL Alton Memorial Hospital * #1548278476 Code: AMH 1 Memorial Dr. Alton, IL 62002 (618) 463-7311
Anderson Hospital * #1053481630 Code: AH 6800 State Rte. 162 Maryville, IL 62062 (618) 288-5711
St. Joseph Hospital #1447352323 Code: SJHH 12866 Troxler Ave. Highland, IL 62249 (618) 651-2600
Saint Clair County, IL HSHS St. Elizabeth's Hospital #1629057302 Code: SEH 1 Saint Elizabeth Blvd. O Fallon, IL 62269 (618) 234-2120 –– 321…