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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 2025, 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 2025.
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 has no deductible for prescription drugs. During the initial coverage phase, you'll pay a copay that varies based on the drug tier and pharmacy type. For example, preferred generic drugs have a $3 copay at preferred pharmacies. For non-preferred drugs, you will pay 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Essence Advantage (HMO) plan offers a wide range of benefits. Inpatient hospital stays have copays ranging from $0 to $240 depending on the service and length of stay. Outpatient services, including emergency and urgent care, have varying copays. The plan covers primary care, hearing, vision, and dental services. Hearing exams have a $20 copay, while vision exams have a $30 copay, and dental cleanings have no copay. The plan also includes coverage for home health services, skilled nursing facilities, and home infusion services, along with coverage for medical equipment, and diagnostic and radiological services.
Inpatient Hospital See details
Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you'll pay a $230 copay for days 1-4, and no copay for days 5-90; Inpatient Hospital Psychiatric has a $240 copay for days 1-8, and no copay for days 9-90. Additional days for Inpatient Hospital-Acute and Psychiatric are covered, but Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services and Observation Services, have a $280 copay. Ambulatory Surgical Center (ASC) Services have a $175 copay, while Individual and Group Sessions for Outpatient Substance Abuse have copays ranging from $10 to $15. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage (HMO) plan, but requires prior authorization. There is no information available about the cost of this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage (HMO) plan. Both ground and air ambulance services have a $220 copay, with no coinsurance, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Essence Advantage (HMO) plan. For Emergency Services, there is a $125 copay, and for Urgently Needed Services, there is a $40 copay; both have no coinsurance, and the Emergency Services copay is waived if admitted to the hospital within 24 hours. Worldwide Urgent Coverage has a $125 copay and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic Services have a $20 copay. Occupational Therapy Services have a $30 copay. Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services have a $30 copay. Individual and Group Mental Health and Psychiatric Sessions have copays of $15 and $10, respectively. Other Health Care Professional and Opioid Treatment Program Services have a minimum copay of $15 and a maximum copay of $15. Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services, Annual Physical Exams, and additional preventive services; however, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. Additional Preventive Services require prior authorization and a doctor referral, and Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) have a copay between $0 and $30.
Hearing Services See details
Hearing Services are covered, including routine hearing exams and fitting/evaluation for hearing aids. Routine hearing exams and fitting/evaluations for hearing aids have a $20 copay and prescription hearing aids (all types) are covered up to $1,000 every two years, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services includes eye exams with a $30 copay, and eyewear benefits including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are limited to one per year, and there is a combined maximum of $200 per year for all eyewear.
Dental Services See details
Dental Services are covered, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatment, with no copay. Medicare Dental Services require prior authorization and a doctor referral, with a $30 copay. Orthodontic Services have a maximum plan benefit of $250 per year. Other services like restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral/maxillofacial surgery are also covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance. The plan does not cover Durable Medical Equipment for use outside the home, or Diabetic Supplies.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with all diagnostic services requiring prior authorization. Diagnostic Procedures/Tests have a copay between $0 and $30, while Lab Services are not covered. Diagnostic Radiological Services have a copay up to $200, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered under the Essence Advantage (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Essence Advantage (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Essence Advantage (HMO) plan, with a prior authorization requirement. For days 1-20, there is no copay, and for days 21-100, the copay is $125.
Other Services See details
Other Services benefits are partially covered under the Essence Advantage (HMO) plan, but acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. The plan also covers Over-the-Counter (OTC) Items, with a maximum benefit coverage amount of $45.00 every three months, and includes Nicotine Replacement Therapy (NRT) and Naloxone coverage as a Part C OTC benefit.
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