2025 Plan Changes Explained
Find answers to our most asked questions
We hope that the topics below will help you gain a better understanding of Essence benefits and any plan changes we've made for 2025. If you need more clarification, don't hesitate to contact us. Our goal is to get you the information you need to feel confident in your health plan.
We know that dental coverage is important for your overall health and well-being, which is why it will continue to be included in most of our 2025 plans. However, there were changes to the way this benefit can be utilized. In 2024, many plans had a built-in dental allowance that was separate from their Flexible Benefits Card allowance for dental services. For most PPO plans in 2025, members must use the Flex Card allowance for all comprehensive and preventive dental services. All HMO plans that offered preventive dental as a built-in benefit in 2024 will continue to offer a set of preventive services that do not require Flex Card use. For comprehensive services, most HMO members must use the Flex Card (if included in your plan).
Essence Advantage Select (HMO) members in the St. Louis area do have a built-in allowance for preventive and comprehensive dental services. This plan's Flex Card is for OTC items only; it can't be used for dental, vision, hearing or medical copays.
Now More Flexibility than Ever Before
We want to assure you that this decision was made with good reasoning and careful consideration of your healthcare needs. The change allows us to offer you more flexibility to use your benefits as you see fit. Affected plans have either received an increase to their Flex Card allowance or the ability to use the Flex Card for certain medical copays. As a reminder, all Flex Cards can be used for non-Medicare-covered dental, vision and hearing items and services. The ability to use the Flex Card on medical copays is a game changer for reducing what our members spend on their healthcare, especially when paired with a low or $0 premium, which Essence proudly offers on most of its plans.
For more information on your plan's dental benefit, see Chapter 4 of your Evidence of Coverage booklet. You can also talk to a benefit specialist by calling 1-877-644-2319 (TTY: 711).
HMO Plan Member Using Your Built-In Dental Benefits?
If you're an HMO plan member with embedded preventive dental coverage (ex. cleanings, exams, X-rays and fluoride treatment), you must use a DentaQuest® provider for those services. For help finding an in-network dental provider, visit DentaQuest.com or contact DentaQuest at 1-800-214-9881 (TTY: 711).
Members of the St. Louis-area Essence Advantage Select (HMO) plan must use a DentaQuest provider for both comprehensive and preventive dental benefits.
HMO or PPO Plan Member Using the Flex Card?
Good news! When using your Flex Card for covered dental services, you may see the dentist of your choice-in- or out-of-network-as long as they agree to treat you.
After 2024, our PPO plans will no longer offer an over-the-counter benefit, and many HMO plans will see a reduction in the amount that can be used for OTC items. This decision allows us to continue providing other essential benefits while maintaining certain costs for important medical and hospital services. By moving these resources to other areas of your plan, we can better meet more of your healthcare needs. We apologize for any inconvenience caused and remain committed to delivering valuable benefits to support your overall well-being.
More Background on OTC Changes
One of the primary reasons behind these adjustments is the continued increase of healthcare costs worldwide. Factors such as rising medical procedure expenses, increasing prescription drug prices and advancements in healthcare technology contribute to the overall increase in healthcare expenses. There are also changes in healthcare regulations that we must abide by, like the Inflation Reduction Act of 2022. This act addresses rising prescription drug costs and helps make medications affordable for all Medicare beneficiaries (learn more about how you'll benefit from this new policy).
Need OTC? We Have Options
Most of our HMO plans have a quarterly allowance for over-the-counter items. If OTC is a must-have benefit, consider reaching out to a benefit specialist at 1-866-509-5398 (TTY: 711) to discuss your options. You can also check OTC availability here. Please note that OTC is not available on all plans or in all markets.
Our transportation benefit will be discontinued as of January 1, 2025. We sincerely apologize for any inconvenience this might cause. Because transportation was underutilized by the majority of our members, we allocated those resources to improve or maintain other costs and benefits within our plans.
We're Here to Help
Although the transportation benefit has been removed, we're still committed to assisting our members find resources for their transportation needs. The Eldercare Locator is a great tool to start with (Eldercare.acl.gov/Public/Index.aspx). If you need more help, our customer service team can provide information, recommendations and support in locating transportation services. Please call 1-866-597-9560 (TTY: 711) for more assistance.
Our pharmacy benefit manager and mail-order pharmacy for 2025 has changed from MedImpact and Birdi, Inc.® to Express Scripts®. Because of this partnership, you'll have access to many preferred pharmacies for lower costs on your Part D prescription drugs.
Preferred pharmacies:
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Mail-order Pharmacy:
For a complete list of preferred and in-network pharmacies, see the Provider Directory on your Member Website.
If you're an Essence member, visit the "Pharmacy" section of your Essence Member Website for:
- A direct link to the Express Scripts member portal (for claims information and to sign up for mail-order services starting January 1, 2025)
- A complete list of preferred pharmacies (in the Provider Directory)
- Our Prescription Drug Formulary
For help with your mail-order prescriptions, you can call Express Scripts starting January 1, 2025 at 1‑800‑282‑2881 (TTY: 1‑800‑759‑1089). You can also reach out to Essence Customer Service.
Note: When picking up prescriptions for the first time in 2025, you'll need to show the pharmacy your 2025 member ID card.
For those who were members in 2024, Essence is working with Express Scripts to help ensure a smooth transition of your current mail-order pharmacy prescriptions from Birdi, Inc. to Express Scripts on your behalf.
The following prescription records will be transferred over from Birdi to Express Scripts mail-order pharmacy by Essence:
- Active and open refills (excludes prescriptions for controlled substance medications (i.e. pain medications) on file from 2024
- Active 2024 prior authorization approvals on file for your Part D medication(s)
The following prescription records will not be transferred over from Birdi to Express Scripts mail-order pharmacy and DO require member action for future prescription fills by Express Scripts mail-order pharmacy (should you choose to utilize their pharmacy delivery services):
- Automated refills will NOT be transferred to Express Scripts. You will need to set up your Express Scripts mail-order pharmacy account and sign up for the Express Scripts automatic prescription refill services. See the instructions above for how to visit the Express Scripts member portal.
- Controlled substances, such as a pain medication, will not be transferred to Express Scripts mail-order pharmacy. You'll need to contact your doctor's office and request that your provider send a new prescription order to Express Scripts mail-order pharmacy. Providers can contact Express Scripts by phone: 1-888-327-9791.
- If there are no remaining refills on your medication(s), you'll need to contact your provider and request that they send a new prescription order to Express Scripts mail-order pharmacy. Providers can contact Express Scripts mail-order pharmacy by phone at 1-888-327-9791.
For those who were members in 2024, Essence is working with Express Scripts to transfer your active (qualifying) 2024 prior authorization approvals on your behalf.
All 2025 Essence members that receive a Part D drug that has a formulary restriction (i.e. a prior authorization or quantity limit) or is a non-formulary drug in 2025, will qualify for a one-time Part D transition fill (for up to a one-month supply) at the pharmacy. If a transition fill is obtained, members will receive a Part D transition letter identifying the 2025 formulary requirement(s) for the drug that must be met to be able to get the drug covered by the plan going forward. Members will need to talk to their provider regarding either a formulary alternative, or having the provider submit a Part D coverage determination request for the affected drug (i.e. a PA request), if there are no appropriate formulary alternatives.
Providers can submit a Part D PA coverage determination request to Express Scripts' PA department by phone at: 1-800-935-6103; via fax at: 1-877-251-5896; or online by visiting ESRX.com/PA. Providers can also contact Essence Customer Service at 1-866-597-9560 for help submitting a Part D coverage determination request.
In 2025, most plans will include a deductible for brand-name and specialty drugs (tiers 3-5). If a Part D deductible is included in your plan, you must pay that amount before your standard copays or coinsurance for those drugs will apply. The deductible will apply once for all drugs on tiers 3-5 regardless of the pharmacy you choose.
A Little Bit of Change for a Whole Lot of Good
This change is a result of the Inflation Reduction Act of 2022 (IRA), which addresses rising prescription drug costs and helps make medications affordable for all Medicare beneficiaries. The Act introduces certain cost-sharing measures, such as the Part D deductible, to help control healthcare inflation and the impact on your prescription drug expenses.
As a result of the IRA, the donut hole has been eliminated, which means you won't pay an increased amount for your medications after reaching the initial coverage limit. Your out-of-pocket obligation is also much lower than in 2024. Medicare Advantage members in 2024 had an initial coverage limit of $5,030; after which, you'd pay increased costs for your drugs until reaching the catastrophic coverage phase of your drug benefit, which was $8,000. In 2025, the most you're responsible for paying for your Part D drugs is $2,000. After that, you'll reach the catastrophic phase, during which you'll pay nothing for covered Part D drugs. Here's a breakdown of how it works and what you can expect in your 2025 Essence plan.
You must meet your Part D deductible (if applicable) before standard cost-sharing will apply.
We understand that managing medication expenses is important and know that our members will greatly benefit from having a significantly lower out-of-pocket maximum. If you're a current member with any further questions or concerns, please don't hesitate to reach out to our customer service team at 1-866-597-9560 (TTY: 711). You can also email customer service at customerservice@essencehealthcare.com.
To enhance our members' healthcare experience, there will be adjustments made to our primary care physician (PCP) network for 2025.
Starting January 1, 2025, certain BJC primary care physicians will no longer serve as designated PCPs for Essence. Rest assured that your Essence plan membership won't be affected. BJC hospitals, specialists and many primary care physicians will remain in-network.
If you were notified that your BJC PCP is no longer in-network, we can help you choose and transition to a new PCP who will continue to provide exceptional care. If you're not sure if your PCP is in-network, try using our provider search tool.
Options for Choosing a New PCP
Options vary based on whether you're an HMO or PPO plan member. You can find your plan name and plan type on your member ID card.
Change your PCP online. This option is only available for HMO members. Visit the "Providers" page on your Essence member website. Scroll to "Changing Your PCP," and then click the "change your PCP online" link. You'll be directed to the online directory with an option to search and select a PCP.
Contact us. This option is available for PPO and HMO members. You can also contact us if you'd rather receive a paper copy of the directory or if you'd like us to help you choose a PCP. Email customerservice@essencehealthcare.com or call Essence Customer Service at 1-866-597-9560 (TTY: 711). If you're choosing a new PCP on your own, make sure to let us know so we can send you an updated ID card.
Essence believes in helping your health and preventing issues before they start. That's why we've partnered with Oura to offer the Oura Ring in certain plans. Oura Ring is a wearable wellness tracker that translates your body's most meaningful messages to transform how you feel every day.
Members with this benefit can order Oura Ring free of charge and also get free access to the Oura App. Your ring syncs with the app to track your heart health, activity, temperature trends, sleep patterns, average blood oxygen, stress indicators and much more.
If you're an Essence member with this benefit in 2025, visit EverythingEssence.com and click "Oura Ring" for more information, including instructions on how to order your sizing kit. Once you've received your kit and sized yourself, you can order your Oura Ring using the link on your sizing kit.
To learn more about everything Oura Ring can do, visit OuraRing.com.
The following plans offer Oura Ring:
St. Louis and Chicago areas-Essence Advantage Choice Plus (PPO)
All other markets-Essence Advantage Choice (PPO)
Essence covers all the hospital and medical services included with Original Medicare-plus prescription drugs and extras like dental, vision and more-for as low as a $0 monthly premium. And when you compare Essence plans with competitors, you'll find we have affordable inpatient hospital copays. Most of our plans have no copay for days six and beyond. We work hard to make sure that costs for services don't prevent our members from getting the care they need. We cover many services for low to no copay at all (in-network primary care visits and lab services, preferred generic drugs and more). Most plans even come with a preloaded Flexible Benefits Card to spend on extra benefits as you see fit.
While we can't guarantee that our costs are the lowest you'll find, we can promise that the care and service you'll receive are top-notch. Essence is consistently highly rated by the Centers for Medicare & Medicaid Services, and those ratings are based on things like member satisfaction, how we keep you healthy, and our benefits and costs. We invite you to shop our plans and see the many great benefits and savings they can offer you. You can also speak to a benefit specialist by calling 1-866-509-5398 (TTY: 711).
Note that benefits and amounts differ by plan and market.
Our customer service team is highly trained, based in the U.S. and is ready to help with enrollment, benefit questions, claims information, finding a provider and more. During certain times of the year, such as the Annual Enrollment Period, wait times may be higher than normal due to increased demand. If you need help faster, we recommend emailing us with your contact information and preferred method of contact, along with what you'd like to discuss. We appreciate your patience and understanding during these busy times.
The Essence Member Website: Plan Information and More-at Your Fingertips
If you're an Essence member, you can find answers to many questions by logging in to EverythingEssence.com. The Essence Member Website is your hub for benefit and claims information, provider and prescription search tools, billing options, important plan documents and more.
How to Reach Us
Our benefit specialists and customer service team are available from 8 a.m. to 8 p.m., seven days a week. You may reach a messaging service on weekends from April 1 to September 30 and holidays. Please leave a message, and your call will be returned the next business day.
Members with 2025 Benefit Questions
Speak to a benefit specialist by calling 1-877-644-2319 (TTY: 711), or email customerservice@essencehealthcare.com.
Member Questions About Current Benefits, Claims, Providers and Billing
Speak to a customer service team member by calling 1-866-597-9560 (TTY: 711), or email customerservice@essencehealthcare.com.
Non-Members with Questions About Essence Plans
Speak to a benefit specialist by calling 1-866-509-5398 (TTY: 711), or email customerservice@essencehealthcare.com.
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