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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 Southwest Missouri and Northwest Arkansas. 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 $3350.00 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 your deductible, you will pay a copay for your prescriptions. For preferred generic drugs, the copay is $3 at a preferred pharmacy and $10 at a standard pharmacy. The plan has no copay for drugs in the specialty tier.
Additional Benefits
The Essence Advantage (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with a $220 copay, and emergency services with a $125 copay. You'll have no copay for primary care visits, and many other services like hearing exams, eye exams, and home health services. This plan also includes coverage for dental, vision, and hearing services, with copays and maximum benefits for specific services. Additionally, it covers services like ambulance, diagnostic and radiological services, and medical equipment with varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with prior authorization. For Inpatient Hospital-Acute, you pay a $275 copay for days 1-5 and no copay for days 6-90; for Inpatient Hospital Psychiatric, you pay a $295 copay for days 1-5 and no copay for days 6-90. Additional days are covered for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and ambulatory surgical center services, are covered with a $220 copay. Outpatient substance abuse services are also covered, with individual sessions costing between $15 and $15, and group sessions costing between $10 and $10. Outpatient blood services are covered with a waived deductible.
Partial Hospitalization See details
Partial Hospitalization is covered, 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 $250 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 have a $125 copay, while Urgently Needed Services have a $45 copay, and Worldwide Emergency Coverage has a $125 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $20 copay, and mental health specialty services with a $15 copay for individual sessions and a $10 copay for group sessions. Podiatry services are not covered, and physical therapy and speech-language pathology services have a $40 copay.
Preventive Services See details
The Essence Advantage (HMO) plan covers preventive services including annual physical exams, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit; however, health education, in-home safety assessments, and several other services are not covered. Remote access technologies have a copay between $0 and $40.
Hearing Services See details
Hearing Services with the Essence Advantage (HMO) plan cover hearing exams with a $20 copay, and prescription hearing aids (all types) with a maximum benefit of $1,000 every two years, but prescription hearing aids for the inner ear, outer ear, and over-the-ear are not covered. This plan also covers routine hearing exams and fitting/evaluation for hearing aids.
Vision Services See details
Essence Advantage (HMO) covers vision services, including eye exams with a $20 copay, and eyewear with a combined maximum benefit of $200 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are also covered, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $20 copay, along with other dental services such as oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics. Orthodontic Services have a maximum plan benefit coverage of $500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Essence Advantage (HMO) plan and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay and between 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered under the Essence Advantage (HMO) plan, with Durable Medical Equipment (DME) covered at 20% coinsurance and no copay, but Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies are covered with no copay, and a 20% coinsurance for Medicare-covered Prosthetic Devices and Medical Supplies; Prosthetic Devices have a 20% coinsurance. Diabetic Equipment is covered, but Diabetic Supplies are not covered; Diabetic Therapeutic Shoes/Inserts are covered at 20% coinsurance.
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, Lab Services have a $5 copay, and Outpatient X-Ray Services have a $20 copay. Diagnostic Radiological Services have a copay of at most $200, and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered under 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 by the Essence Advantage (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and 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, there is no copay, and for days 21-100, the copay is $160 per day.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items, with a maximum benefit of $50.00 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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