PARTCRX

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
Essence HealthCare
CMS Rating
Plan Type
HMO
Annual Deductible
$0.00

What To Know About This Plan

  • This plan has health and drug coverage

Plan Details

Costs and Other Important Information

Plan Year:
2014
Optional Supplemental Benefits?
No
Choice of Doctors?
Plan Doctors Only
Prescription Drugs Covered?
Yes
Out-Of-Pocket Spending Limit
$4,950 In-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
Days 1-7: $260 copay per day. Days 8-90: $0 copay per day
Not Applicable
Inpatient Mental Health Care
Days 1-6: $245 copay per day. Days 7-90: $0 copay per day
Not Applicable
Skilled Nursing Facility (SNF)
Days 1-20: $25 copay per day. Days 21-100: $0 copay per day
Not Applicable
Home Health Care
$0
Not Applicable
Doctor Office Visits
$11 maximum per visit
Not Applicable
Outpatient Services
$250 maximum or 20% maximum per visit
Not Applicable
Ambulance Services
$200 maximum
Not Applicable
Emergency Care
$65 maximum per visit
Not Applicable
Durable Medical Equipment
20% maximum per item
Not Applicable
Kidney Disease and Conditions
20% maximum per visit
Not Applicable
Specialist Office Visit
$45 maximum per visit
Not Applicable

Prescription Drug Coverage

Drugs Covered under Medicare Part B

General

20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.


Drugs Covered under Medicare Part D

General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.essencehealthcare.com on the web.

Different out-of-pocket costs may apply for people who
  • have limited incomes,
  • live in long term care facilities, or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.


The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and a Part D plan.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

Some drugs have quantity limits.

Your provider must get prior authorization from Essence Advantage (HMO) for certain drugs.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

If you request a formulary exception for a drug and Essence Advantage (HMO) approves the exception, you will pay Tier 4: Non-Preferred Brand cost sharing for that drug.

In-Network

$0 deductible.

Initial Coverage

You pay the following until total yearly drug costs reach $2,850:

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs from a preferred and non-preferred pharmacy the following way(s):

Tier 1: Preferred Generic

  • $0 copay for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • $0 copay for a two-month (62-day) supply of drugs in this tier from a preferred pharmacy


  • $0 copay for a three-month (93-day) supply of drugs in this tier from a preferred pharmacy


  • $7 copay for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • $14 copay for a two-month (62-day) supply of drugs in this tier from a non-preferred pharmacy


  • $21 copay for a three-month (93-day) supply of drugs in this tier from a non-preferred pharmacy


  • Tier 2: Non-Preferred Generic

  • $0 copay for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • $0 copay for a two-month (62-day) supply of drugs in this tier from a preferred pharmacy


  • $0 copay for a three-month (93-day) supply of drugs in this tier from a preferred pharmacy


  • $10 copay for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • $20 copay for a two-month (62-day) supply of drugs in this tier from a non-preferred pharmacy


  • $30 copay for a three-month (93-day) supply of drugs in this tier from a non-preferred pharmacy


  • Tier 3: Preferred Brand

  • $37 copay for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • $74 copay for a two-month (62-day) supply of drugs in this tier from a preferred pharmacy


  • $111 copay for a three-month (93-day) supply of drugs in this tier from a preferred pharmacy


  • $42 copay for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • $84 copay for a two-month (62-day) supply of drugs in this tier from a non-preferred pharmacy


  • $126 copay for a three-month (93-day) supply of drugs in this tier from a non-preferred pharmacy


  • Tier 4: Non-Preferred Brand

  • $75 copay for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • $150 copay for a two-month (62-day) supply of drugs in this tier from a preferred pharmacy


  • $225 copay for a three-month (93-day) supply of drugs in this tier from a preferred pharmacy


  • $85 copay for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • $170 copay for a two-month (62-day) supply of drugs in this tier from a non-preferred pharmacy


  • $255 copay for a three-month (93-day) supply of drugs in this tier from a non-preferred pharmacy


Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier from a preferred pharmacy


  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier from a non-preferred pharmacy


  • Long Term Care Pharmacy

    Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

    You can get drugs the following way(s):

    Tier 1: Preferred Generic

    • $7 copay for a one-month (31-day) supply of drugs in this tier


    • Tier 2: Non-Preferred Generic

    • $10 copay for a one-month (31-day) supply of drugs in this tier


    • Tier 3: Preferred Brand

    • $42 copay for a one-month (31-day) supply of drugs in this tier


    • Tier 4: Non-Preferred Brand

    • $85 copay for a one-month (31-day) supply of drugs in this tier


    • Tier 5: Specialty Tier

    • 33% coinsurance for a one-month (31-day) supply of drugs in this tier



    Mail Order


    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

    You can get drugs the following way(s):

    Tier 1: Preferred Generic

    • $7 copay for a one-month (31-day) supply of drugs in this tier


    • $14 copay for a two-month (62-day) supply of drugs in this tier


    • $21 copay for a three-month (93-day) supply of drugs in this tier


    • Tier 2: Non-Preferred Generic

    • $10 copay for a one-month (31-day) supply of drugs in this tier


    • $20 copay for a two-month (62-day) supply of drugs in this tier


    • $30 copay for a three-month (93-day) supply of drugs in this tier


    • Tier 3: Preferred Brand

    • $42 copay for a one-month (31-day) supply of drugs in this tier


    • $84 copay for a two-month (62-day) supply of drugs in this tier


    • $126 copay for a three-month (93-day) supply of drugs in this tier


    • Tier 4: Non-Preferred Brand

    • $85 copay for a one-month (31-day) supply of drugs in this tier


    • $170 copay for a two-month (62-day) supply of drugs in this tier


    • $255 copay for a three-month (93-day) supply of drugs in this tier


    Tier 5: Specialty Tier

  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier


  • Coverage Gap

    After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550.

    Catastrophic Coverage

    After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:
    • 5% coinsurance, or
    • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.


    Out-of-Network

    Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Essence Advantage (HMO).

    You can get out-of-network drugs the following way:

    Out-of-Network Initial Coverage

    You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850:

    Out-of-Network Initial Coverage

    Tier 1: Preferred Generic

    • $7 copay for a one-month (31-day) supply of drugs in this tier


    • Tier 2: Non-Preferred Generic

    • $10 copay for a one-month (31-day) supply of drugs in this tier


    • Tier 3: Preferred Brand

    • $42 copay for a one-month (31-day) supply of drugs in this tier


    • Tier 4: Non-Preferred Brand

    • $85 copay for a one-month (31-day) supply of drugs in this tier


    • Tier 5: Specialty Tier

    • 33% coinsurance for a one-month (31-day) supply of drugs in this tier


    Out-of-Network Coverage Gap

    You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).

    Out-of-Network Catastrophic Coverage

    After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of:
    • 5% coinsurance, or
    • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.



    Other Services

    Inpatient Care

    Doctor and Hospital Choice



    In-Network

    You must go to network doctors, specialists, and hospitals.

    Referral required for network specialists (for certain benefits).


    Inpatient Hospital Care



    In-Network

    No limit to the number of days covered by the plan each hospital stay.

    For Medicare-covered hospital stays:

    • Days 1 - 7: $260 copay per day


    • Days 8 - 90: $0 copay per day


    $0 copay for additional non-Medicare-covered hospital days

    Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


    Outpatient Care

    Inpatient Mental Health Care



    In-Network

    Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days.

    For Medicare-covered hospital stays:

    • Days 1 - 6: $245 copay per day


    • Days 7 - 90: $0 copay per day


    $0 copay for additional non-Medicare-covered hospital days

    Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


    Skilled Nursing Facility (SNF)



    General

    Authorization rules may apply.

    In-Network

    Plan covers up to 100 days each benefit period

    No prior hospital stay is required.

    For Medicare-covered SNF stays:

    • Days 1 - 20: $25 copay per day


    • Days 21 - 100: $0 copay per day



    Home Health Care



    In-Network

    $0 copay for Medicare-covered home health visits


    Hospice



    General

    You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.


    Doctor Office Visits



    In-Network

    $11 copay for each Medicare-covered primary care doctor visit.

    $45 copay for each Medicare-covered specialist visit.


    Outpatient Medical Services and Supplies

    Chiropractic Services



    In-Network

    $15 copay for each Medicare-covered chiropractic visit

    Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).


    Podiatry Services



    In-Network

    $45 copay for each Medicare-covered podiatry visit

    Medicare-covered podiatry visits are for medically necessary foot care.


    Outpatient Mental Health Care



    General

    Authorization rules may apply.

    In-Network

    $35 copay for each Medicare-covered individual therapy visit

    $25 copay for each Medicare-covered group therapy visit

    $35 copay for each Medicare-covered individual therapy visit with a psychiatrist

    $25 copay for each Medicare-covered group therapy visit with a psychiatrist

    $0 copay for Medicare-covered partial hospitalization program services


    Outpatient Substance Abuse Care



    General

    Authorization rules may apply.

    In-Network

    $35 copay for Medicare-covered individual substance abuse outpatient treatment visits

    $25 copay for Medicare-covered group substance abuse outpatient treatment visits


    Outpatient Services



    General

    Authorization rules may apply.

    In-Network

    $175 copay for each Medicare-covered ambulatory surgical center visit

    $250 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit


    Ambulance Services



    General

    Authorization rules may apply.

    In-Network

    $200 copay for Medicare-covered ambulance benefits.


    Emergency Care



    General

    $65 copay for Medicare-covered emergency room visits

    Worldwide coverage.

    If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit.


    Urgently Needed Care



    General

    $25 copay for Medicare-covered urgently-needed-care visits


    Outpatient Rehabilitation Services



    General

    Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.

    In-Network

    $40 copay for Medicare-covered Occupational Therapy visits

    $40 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits


    Durable Medical Equipment



    General

    Authorization rules may apply.

    In-Network

    20% of the cost for Medicare-covered durable medical equipment

    You may pay less if you purchase these items from the plan's preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors.


    Preventive Services

    Prosthetic Devices



    General

    Authorization rules may apply.

    In-Network

    20% of the cost for Medicare-covered prosthetic devices

    20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices


    Diabetes Programs and Supplies



    General

    Authorization rules may apply.

    In-Network

    $0 copay for Medicare-covered Diabetes self-management training

    0% of the cost for Medicare-covered Diabetes monitoring supplies

    20% of the cost for Medicare-covered Therapeutic shoes or inserts

    Diabetic Supplies and Services are limited to specific manufacturers, products and/or brands. Contact the plan for a list of covered supplies.


    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services



    General

    Authorization rules may apply.

    In-Network

    $0 to $15 copay for Medicare-covered lab services

    0% to 20% of the cost for Medicare-covered diagnostic procedures and tests

    $20 copay for Medicare-covered X-rays

    20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)

    20% of the cost for Medicare-covered therapeutic radiology services


    Cardiac and Pulmonary Rehabilitation Services



    General

    Authorization rules may apply.

    In-Network

    $40 copay for Medicare-covered Cardiac Rehabilitation Services

    $40 copay for Medicare-covered Intensive Cardiac Rehabilitation Services

    $40 copay for Medicare-covered Pulmonary Rehabilitation Services


    Additional Benefits

    Preventive Services



    General

    $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.


    Kidney Disease and Conditions



    In-Network

    20% of the cost for Medicare-covered renal dialysis

    $0 copay for Medicare-covered kidney disease education services


    Dental Services



    In-Network

    $30 copay for Medicare-covered dental benefits

    $30 copay for a supplemental visit that includes:

    • up to 2 oral exam(s) every year


    • up to 2 cleaning(s) every year


    • up to 1 fluoride treatment(s) every year


    • up to 1 dental x-ray(s) every year



    Hearing Services



    In-Network

    Hearing aids not covered.

    $25 copay for Medicare-covered diagnostic hearing exams

    $25 copay for supplemental routine hearing exams


    Vision Services



    In-Network

    $30 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk

    $30 copay for up to 1 supplemental routine eye exam(s) every year

    $30 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.

    $30 copay for up to 1 pair(s) of eyeglasses (lenses and frames) every year

    $30 copay for up to 1 pair(s) of contact lenses every year


    Cost Sharing Information

    Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

    30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
    Tier 1: Preferred Generic$0 copay$7 copay$7 copay
    Tier 2: Non-Preferred Generic$0 copay$10 copay$10 copay
    Tier 3: Preferred Brand Name$37 copay$42 copay$42 copay
    Tier 4: Non-Preferred Brand Name$75 copay$85 copay$85 copay
    Tier 5: Specialty Tier33% coinsurance33% coinsurance33% coinsurance
    90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
    Tier 1: Preferred Generic$0 copay$21 copay$21 copay
    Tier 2: Non-Preferred Generic$0 copay$30 copay$30 copay
    Tier 3: Preferred Brand Name$111 copay$126 copay$126 copay
    Tier 4: Non-Preferred Brand Name$225 copay$255 copay$255 copay
    Tier 5: Specialty Tier

    CMS Ratings

    Staying healthy - screenings, tests and vaccines

    Breast cancer screening
    Not Rated
    Colorectal cancer screening
    Cholesterol screening for patients with heart disease
    Glaucoma testing
    Annual flu vaccine
    Pneumonia vaccine
    Improving or maintaining physical health
    Improving or maintaining mental health
    Monitoring physical ability
    Access to primary care doctor visits
    Adult BMI assessment

    Managing Chronic Conditions

    Care for older adults – medication review
    Not Rated
    Care for older adults – functional status assessment
    Not Rated
    Care for older adults – Pain screening
    Not Rated
    Osteoporosis management in women who had a fracture
    Diabetes care – eye exam
    Diabetes care – kidney disease monitoring
    Diabetes care – blood sugar controlled
    Diabetes care – cholesterol controlled
    Controlling blood pressure
    Rheumatoid arthritis management
    Improving bladder control
    Reducing the risk of falling
    Plan all-cause readmissions

    Ratings of Plan Responsiveness and Care

    Getting needed care
    Getting appointments and care quickly
    Customer service
    Overall rating of health care quality
    Overall rating of plan

    Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

    Complaints about the health plan
    Beneficiary access and performance problems
    Members choosing to leave the plan
    Plan makes timely decision about appeals
    Reviewing appeals decisions
    Call center – foreign language interpreter and TTY/TDD availability

    Physician Finder

    Physicians that accept Essence Advantage (HMO) for Missouri

    /
    DOERR, THOMAS
    13303 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    HAMMOND, DAVID
    13303 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    ROETHEMEYER, JANELLE
    13303 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    RICHARDSON, DONALD
    12345 W BEND DR
    SAINT LOUIS, MO 63128
    SAITZ, ROBERT
    5034 GRIFFIN RD
    SAINT LOUIS, MO 63128
    THAMPY, K.
    10004 KENNERLY RD
    SAINT LOUIS, MO 63128
    AL-JOUNDI, TAMMAM
    10012 KENNERLY ROAD
    ST LOUIS, MO 63128
    BENZ, STEPHEN
    12152 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    ASSI, NIZAR
    10012 KENNERLY RD
    SAINT LOUIS, MO 63128
    AL-JOUNDI, BASSAM
    10012 KENNERLY ROAD
    ST LOUIS, MO 63128
    MARKENSON, ROBERT
    12152 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    MCMAHON, ROBERT
    5139 MATTIS RD
    SAINT LOUIS, MO 63128
    CALCATERRA, CURT
    5034 GRIFFIN RD
    SAINT LOUIS, MO 63128
    CIZEK, KATHLEEN
    5034 GRIFFIN RD
    SAINT LOUIS, MO 63128
    FEDAK, MICHAEL
    13303 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    GEEKIE, ROBERT
    5034 GRIFFIN RD
    SAINT LOUIS, MO 63128
    MAASSEN, GARY
    5034 GRIFFIN RD
    SAINT LOUIS, MO 63128
    OERTLI, ROBERT
    12345 W BEND DR
    SAINT LOUIS, MO 63128
    MUCHNICK, RICHARD
    12345 W BEND DR
    SAINT LOUIS, MO 63128
    CRANE, BENJAMIN
    12639 OLD TESSON RD
    SAINT LOUIS, MO 63128
    ZIPPAY, AMY
    12152 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    FAGAN, DAVID
    12152 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    YOUNIS, LIWA
    10012 KENERLY ROAD
    ST LOUIS, MO 63128
    LEE, THOMAS
    12152 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    MAHON, GERALD
    13303 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    Details
    THOMAS DOERR, M.D.
    Phone Number
    (314) 842-4774
    Office Locations
    13303 TESSON FERRY RD
    SAINT LOUIS, MO 63128
    13303 TESSON FERRY RD SAINT LOUIS MO, 63128

    Community Q&A

    Do you have questions about this plan?

    Get answers from the HealthPocket community.

    Similar Plans

    PremiumPlan NameCMS Rating
    $15.00
    Humana Gold Choice H8145-120 (PFFS)
    Select
    $0.00
    Coventry Advantage Plus (HMO-POS)
    Select
    $19.10
    WellCare Classic (PDP)
    Select
    $0.00
    UnitedHealthcare MedicareDirect Rx (PFFS)
    Select
    $70.00
    Essence Advantage Plus (HMO)
    Select

    Related Articles

    Related Searches