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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 Boone and Callaway Counties. 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 a $295.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3500.00 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 a $295 deductible for prescription drugs. After you meet the deductible, you will pay a copay for your prescriptions depending on the drug tier and pharmacy. For preferred generic drugs, you'll pay a $3 copay at a preferred pharmacy and a $12 copay at a standard pharmacy. Specialty tier drugs have no copay.
Additional Benefits
The Essence Advantage (HMO) plan offers a wide range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays. You'll find coverage for emergency services, primary care, preventive services, and specialized services like hearing, vision, and dental care. The plan also covers services such as ambulance, home health, and skilled nursing facilities, with specific copays or coinsurance amounts. This plan includes additional benefits like coverage for home infusion, dialysis, and medical equipment, each with its own cost-sharing structure. Other covered services include diagnostic and radiological services, and a quarterly allowance for over-the-counter items. However, some services like cardiac rehabilitation, additional hours of care, and certain types of hearing aids are not covered.
Inpatient Hospital See details
The Essence Advantage (HMO) plan covers Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $310 copay for days 1-4 and no copay for days 5-90. For Inpatient Hospital Psychiatric, you will pay a $295 copay for days 1-6 and no copay for days 7-90. Additional days for both are covered, but Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services with the Essence Advantage (HMO) plan includes coverage for outpatient hospital services with a $250 copay, observation services with a $250 copay, and ambulatory surgical center services with a $175 copay. Outpatient substance abuse services include individual sessions with a $15 copay, and group sessions with a $10 copay, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage (HMO) plan, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage (HMO) plan. Ground and air ambulance services have a $200 copay with no coinsurance, while 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 under the Essence Advantage (HMO) plan. Emergency Services has a $125 copay, Urgently Needed Services has a $40 copay, and Worldwide Emergency Coverage has a $125 copay; all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $35 copay, and mental health specialty services with a $10-$15 copay. This plan also covers physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits, and opioid treatment program services with a $15 copay. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services, including Medicare-covered preventive services and annual physical exams, are covered. Additional preventive services, such as Remote Access Technologies, are covered, with a copay between $0 and $40 for some services.
Hearing Services See details
Hearing Services are covered, including Routine Hearing Exams and Fitting/Evaluation for Hearing Aids, each with a $20 copay; Prescription Hearing Aids (all types) are covered, while Prescription Hearing Aids for the Inner Ear, Outer Ear, and Over the Ear are not covered; OTC Hearing Aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $35 copay, and also includes coverage for eyewear. Eyewear has a combined maximum benefit of $200 per year, and also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Upgrades are not covered.
Dental Services See details
The Essence Advantage (HMO) plan covers dental services, including oral exams with a $35 copay, dental x-rays, prophylaxis (cleaning) with a $35 copay, fluoride treatment with a $35 copay, and orthodontic services with a $650 annual maximum. Restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are all covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and a coinsurance between 0% and 20%, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%. Prior authorization is required.
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 are covered by Essence Advantage (HMO). Durable Medical Equipment (DME) has a 20% coinsurance with prior authorization required, and Prosthetic Devices also have a 20% coinsurance. Medical Supplies have a 20% coinsurance and Diabetic Therapeutic Shoes/Inserts have 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 are covered by the Essence Advantage (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $30, while Lab Services are not covered. Diagnostic Radiological Services have a copay of 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 by the Essence Advantage (HMO) plan with no copay and no coinsurance, but a referral is required. 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. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Essence Advantage (HMO) plan, but require prior authorization. For days 1-20, the copay is $20 per day, and for days 21-100, the copay is $125 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Essence Advantage (HMO) plan covers over-the-counter (OTC) items with a maximum benefit coverage amount of $52.50 every three months. 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.
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