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Essence Advantage Plus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage Plus (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Advantage Plus (HMO) in 2026, please refer to our full plan details page.
Essence Advantage Plus (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 Plus (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 Plus (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 Plus (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $59.00. 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 $2900.00 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 Plus (HMO) offers excellent prescription drug coverage starting with a $0 drug deductible, meaning your benefits begin immediately. For Tier 1 preferred generics and Tier 6 select care drugs, you will pay no copay at preferred pharmacies or through standard mail order. Tier 2 generic drugs are also highly affordable, with copays as low as $3 for a one-month supply at preferred pharmacies and standard mail order. For brand-name and specialty medications, Tier 3 preferred brands require a $45 copay and Tier 4 non-preferred drugs require a $95 copay for a one-month supply at preferred pharmacies. Tier 5 specialty drugs have a 33% coinsurance for a one-month supply at preferred, standard, and mail-order pharmacies. Utilizing standard mail order for three-month supplies of Tier 2, 3, and 4 drugs can also provide significant cost savings.
Additional Benefits
The Essence Advantage Plus (HMO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, including no copay for primary care doctor visits and a $30 copay for specialists. Inpatient hospital stays require a $250 daily copay for days one through seven, with no copay for additional days, while emergency room visits carry a $125 copay. Outpatient surgical services require a $125 to $250 copay, and home health care and preventive services are covered with no copays. This plan also features supplemental benefits to lower everyday health costs, including preventive and comprehensive dental care with no copay up to a $2,000 annual limit. Members also enjoy no copays on eyewear up to $300 annually, hearing aid coverage up to $1,000 every two years, and a $40 quarterly allowance for over-the-counter items. Additionally, the plan provides up to 20 one-way trips per year to plan-approved locations with no copay.
Inpatient Hospital See details
Essence Advantage Plus (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $250 daily copay for days 1 through 7 and no copay for days 8 and beyond. This benefit is partially covered, as upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Essence Advantage Plus (HMO) covers outpatient services with no coinsurance, including a $250 copay for outpatient hospital and observation services and a $125 copay for ambulatory surgical center services. Outpatient substance abuse services require a $10 to $15 copay per session with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Essence Advantage Plus (HMO) with no copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Essence Advantage Plus (HMO) covers ground and air ambulance services with a $160 copay and no coinsurance, subject to prior authorization. Transportation services are partially covered with no copay or coinsurance, providing up to 20 one-way trips per year via bus or subway to plan-approved locations, though trips to any other health-related locations are not covered.
Emergency Services See details
Essence Advantage Plus (HMO) covers emergency services with a $125 copay (waived if admitted within 24 hours) and urgently needed services with a $30 copay, both with no coinsurance. Worldwide emergency and urgent services are partially covered with a $125 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage Plus (HMO) offers primary care physician services with no copay and no coinsurance, and specialist services for a $30 copay and no coinsurance. Physical, occupational, and speech therapy services require a $20 copay and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Essence Advantage Plus (HMO) with no copay and no coinsurance for covered services like annual physical exams, kidney disease education, glaucoma screenings, and physical or memory fitness benefits. However, several additional preventive services are not covered, including health education, personal emergency response systems, nutritional or dietary benefits, and in-home safety assessments.
Hearing Services See details
Essence Advantage Plus (HMO) partially covers hearing services, offering routine exams and fitting evaluations for a $20 copay and no coinsurance, with no deductible. Prescription hearing aids are covered with no copay or coinsurance up to a $1,000 limit every two years, but OTC hearing aids and 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 Plus (HMO), featuring a $30 copay, no coinsurance, and no deductible for one annual routine eye exam, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $300 annual limit for contacts or eyeglasses, though upgrades are not covered.
Dental Services See details
Dental Services are partially covered by Essence Advantage Plus (HMO), offering Medicare-covered dental services for a $30 copay and no coinsurance, and preventive and comprehensive services with no copay and no coinsurance up to a $2,000 yearly maximum. Other diagnostic dental services and other preventive dental services are not covered.
Home Infusion bundled Services See details
Essence Advantage Plus (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin requires a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage Plus (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is partially covered by Essence Advantage Plus (HMO) with no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes, with prior authorization required. Diabetic supplies are not covered under this plan.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Essence Advantage Plus (HMO), as lab services are not covered. Covered diagnostic procedures and tests require no coinsurance and a $0 to $30 copay, while diagnostic radiological services have no copay or coinsurance, outpatient X-rays require a $20 copay plus coinsurance, and therapeutic radiological services require a 20% coinsurance and a copay.
Home Health Services See details
Home health services are covered under the Essence Advantage Plus (HMO) with no copay and no coinsurance, though a referral is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Essence Advantage Plus (HMO) with no coinsurance, although a referral is required. While some services are covered, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $20 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Essence Advantage Plus (HMO) with no coinsurance and requires prior authorization, with no prior three-day hospital stay required. There is no copay for days 1 through 20 and a $125 copay for days 21 through 100, though additional days beyond Medicare-covered limits are not covered.
Other Services See details
Other Services under the Essence Advantage Plus (HMO) are partially covered, offering over-the-counter (OTC) items with no copay and no coinsurance up to a $40 maximum benefit every three months via reimbursement. Acupuncture, meal benefits, and other additional services are not covered.
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