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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 2025, 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 2025.
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 $58.00. 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) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay for your prescriptions, which varies depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $3 copay at preferred pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. If you qualify for the low-income subsidy (LIS), your monthly premium will be reduced to $15.20.
Additional Benefits
The Essence Advantage Plus (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays for services like hospital visits and surgeries. Emergency services and primary care visits have copays, and the plan also covers preventive, hearing, vision, and dental services, each with its own cost structure, including copays and coinsurance. Additional benefits include ambulance and transportation services, home health services with no copay, and coverage for medical equipment, dialysis services, and home infusion. The plan also provides coverage for hearing aids and eyewear. However, some services, such as cardiac rehabilitation and additional hours of care, are not covered by this plan.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered. For Inpatient Hospital-Acute, you'll pay a $195 copay for days 1-5, and no copay for days 6-90, while for Inpatient Hospital Psychiatric, you'll pay a $195 copay for days 1-6, and no copay for days 7-90. Additional days for both acute and psychiatric care are covered with no copay. Non-Medicare-covered stays and upgrades for acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient services are covered by the Essence Advantage Plus (HMO) plan, including outpatient hospital services with a $175 copay, observation services with a $175 copay, and ambulatory surgical center services with a $125 copay. Outpatient substance abuse services are covered, with individual sessions costing $15 and group sessions costing $10. Outpatient blood services are also covered, with three pints deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage Plus (HMO) plan, but requires prior authorization. There is no information about the cost of services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Essence Advantage Plus (HMO) plan. Ground and Air Ambulance Services have a $160 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services has a $30 copay; all services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Plus (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services require a $20 copay, while physician specialist services have a $30 copay. Individual and group mental health and psychiatric sessions have copays of $15 and $10, respectively, and physical therapy and speech-language pathology services have a $20 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Essence Advantage Plus (HMO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams, and additional preventive services that require prior authorization and a doctor's referral. The plan also offers a fitness benefit and remote access technologies with a copay between $0 and $30. However, health education, in-home safety assessments, personal emergency response systems, and other services are not covered.
Hearing Services See details
Hearing Services include hearing exams, with a $20 copay, and fitting/evaluation for hearing aids, as well as prescription hearing aids, with a maximum plan benefit of $1,000 every two years. Prescription hearing aids are limited to 2 visits every two years, and inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
The Essence Advantage Plus (HMO) plan covers vision services, including routine eye exams with a $30 copay. The plan also covers eyewear, with a combined maximum benefit of $200 every year, as well as contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. However, upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay and other dental services, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatment with specific visit limits. The plan also covers Orthodontic Services with a maximum benefit of $240 per year, along with restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and the coinsurance ranges from 0% to 20%. The coinsurance for both Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage Plus (HMO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay between $0 and $30, and Diagnostic Radiological Services with a copay of up to $200. Outpatient X-Ray Services have a $20 copay, and Therapeutic Radiological Services have a 20% coinsurance. Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Plus (HMO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Essence Advantage Plus (HMO) plan. Specifically, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Essence Advantage Plus (HMO) plan, with a $0 copay for days 1-20, and a $125 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items, with a maximum benefit coverage amount of $40 every three months. Acupuncture, Meal Benefit, 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.
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