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Essence Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Advantage (HMO) in 2026, please refer to our full plan details page.
Essence Advantage (HMO) is a HMO plan offered by Lumeris Group Holdings Corporation available for enrollment in 2025 to people living in St. Louis Metropolitan Area. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Essence Advantage (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Essence Advantage (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Essence Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3400.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Essence Advantage (HMO) plan offers a $0 drug deductible, allowing your prescription drug coverage to begin immediately. You will pay no copay for Tier 1 preferred generic drugs at preferred pharmacies and standard mail order, and Tier 6 select care drugs also feature no copay across all network pharmacies. Tier 2 generic drugs are highly affordable, starting with a low $3 copay for a one-month supply at preferred pharmacies and standard mail order. For higher-tier medications, Tier 3 preferred brand drugs require a $45 copay at preferred pharmacies, while Tier 4 non-preferred drugs have a $75 copay. Standard pharmacies generally feature slightly higher costs, such as a $4 copay for Tier 1 and a $12 copay for Tier 2 generic drugs. Specialty drugs in Tier 5 require a 33% coinsurance for a one-month supply at preferred, standard, and mail-order pharmacies.
Additional Benefits
The Essence Advantage (HMO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copay for primary care visits, home health services, and annual preventive screenings. For hospital care, inpatient stays require a $325 daily copay for the first seven days and no copay for subsequent days, with no coinsurance. Emergency care is available with a $150 copay, while urgent care visits require a $40 copay. Specialist visits, physical therapy, and routine eye exams are covered with a $30 copay, while hearing exams require a $20 copay. The plan also features valuable extra benefits with no copay, including prescription hearing aids up to a $1,000 limit every two years, eyewear up to a $200 annual limit, and select preventive and comprehensive dental services. Additionally, over-the-counter items are covered with no copay up to a $45 limit every three months, while medical equipment and dialysis require a 20% coinsurance.
Inpatient Hospital See details
Essence Advantage (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $325 daily copay for days 1 through 7 and no copay for days 8 and beyond. Prior authorization is required for these services, and upgrades as well as non-Medicare-covered stays are not covered.
Outpatient Services See details
Essence Advantage (HMO) covers outpatient services with no coinsurance, featuring a $300 copay for outpatient hospital and observation services, and a $175 copay for ambulatory surgical center services. Outpatient substance abuse services are covered with a $10 to $15 copay and no coinsurance, while outpatient blood services are available with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Essence Advantage (HMO) with no copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Essence Advantage (HMO) covers Medicare-approved ground and air ambulance services with a $220 copay and no coinsurance, subject to prior authorization. Transportation services to plan-approved health-related locations via bus or subway are covered with no copay or coinsurance for up to 20 one-way trips per year, though transportation to any other health-related location is not covered.
Emergency Services See details
Essence Advantage (HMO) covers emergency services with a $150 copay (waived if admitted within 24 hours) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent care are also covered with a $150 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Primary care services under Essence Advantage (HMO) are offered with no copay and no coinsurance, while specialist visits, physical therapy, and occupational therapy require a $30 copay and no coinsurance. Mental health and psychiatric services have a $15 copay for individual sessions and a $10 copay for group sessions with no coinsurance, but podiatry is not covered, and some chiropractic services are covered but routine and other chiropractic services are not.
Preventive Services See details
Preventive services are covered by Essence Advantage (HMO) with no copay and no coinsurance for annual physical exams, kidney disease education, and screenings like glaucoma and diabetes self-management. While a memory fitness benefit is included, multiple supplemental preventive services—including health education, weight management programs, and in-home safety assessments—are not covered.
Hearing Services See details
Essence Advantage (HMO) covers hearing exams with a $20 copay and prescription hearing aids with no copay, featuring no coinsurance and no deductible for these services, up to a $1,000 maximum benefit every two years. Hearing services are partially covered under this plan because OTC hearing aids, along with inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by Essence Advantage (HMO), featuring one routine eye exam per year for a $30 copay and no coinsurance, with other eye exams excluded. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 annual limit, but upgrades are not covered.
Dental Services See details
Essence Advantage (HMO) provides partially covered dental services, with other diagnostic and other preventive dental services being not covered. Medicare-covered dental services require a $30 copay and no coinsurance, while other covered preventive and comprehensive services have no copay and no coinsurance, with a $250 annual limit on orthodontic services.
Home Infusion bundled Services See details
Home infusion bundled services are covered under the Essence Advantage (HMO) plan with no copay, although prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs incur no coinsurance up to a 20% coinsurance, while Part B insulin drugs have a $35 copay and no coinsurance up to a 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Essence Advantage (HMO) covers medical equipment with no copay and a 20% coinsurance for durable medical equipment, prosthetic devices, medical supplies, and diabetic therapeutic shoes and inserts, with prior authorization required. This benefit is partially covered because diabetic supplies are not covered under the plan.
Diagnostic and Radiological Services See details
Essence Advantage (HMO) partially covers diagnostic and radiological services, requiring prior authorization for all services while excluding lab services from coverage. Covered diagnostic procedures and diagnostic radiological services feature no coinsurance and copays starting at $0 (up to $30), whereas outpatient x-rays require a $20 copay plus coinsurance, and therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Essence Advantage (HMO) with no copay and no coinsurance, though a referral is required.
Cardiac Rehabilitation Services See details
Some Cardiac Rehabilitation Services are covered by Essence Advantage (HMO) with no coinsurance and a required referral, but standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and carry a $25 copay.
Skilled Nursing Facility (SNF) See details
Essence Advantage (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement, though prior authorization is required. There is no copay for days 1 through 20 and a $125 daily copay for days 21 through 100, but additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Essence Advantage (HMO) partially covers other services, providing over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $45 every three months. Acupuncture, meal benefits, and dual-eligible SNP services are not covered under this plan.
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