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Essence Advantage Select (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage Select (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Advantage Select (HMO) in 2025, please refer to our full plan details page.
Essence Advantage Select (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 Select (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 Select (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 Select (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 $3900.00 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 Select (HMO) plan has a $295 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 pharmacy type. 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 your Part D covered drugs. However, if you qualify for the low-income subsidy, you will not have to pay the deductible and will have no copay for Part D drugs.
Additional Benefits
The Essence Advantage Select (HMO) plan offers a range of benefits, including inpatient hospital stays with copays ranging from $0 to $260, and outpatient services with copays from $10 to $250. Emergency, urgent, and worldwide emergency services are covered with copays, and primary care services have copays depending on the service. Preventive services are covered with no copay, and the plan includes hearing and vision services with copays. Dental services include oral exams, x-rays, and cleanings with no copay, and other services up to a $4,000 annual maximum. The plan also provides coverage for home infusion, dialysis, medical equipment, diagnostic services, and home health services.
Inpatient Hospital See details
The Essence Advantage Select (HMO) plan covers inpatient hospital services, including acute and psychiatric care, with prior authorization required. For inpatient hospital-acute, you'll pay a $240 copay for days 1-5, and no copay for days 6-90. For inpatient hospital psychiatric, you'll pay a $260 copay for days 1-6, and no copay for days 7-90. Additional days for inpatient hospital-acute and psychiatric are covered, while non-Medicare-covered stays and upgrades for inpatient hospital-acute and psychiatric are not covered.
Outpatient Services See details
Outpatient Services include outpatient hospital services and observation services, both with a $250 copay, Ambulatory Surgical Center (ASC) services with a $175 copay, and outpatient substance abuse services with a $10-$15 copay. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage Select (HMO) plan, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and Air Ambulance Services each have a $220 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 Services are covered by the Essence Advantage Select (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $35 copay, and there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Select (HMO) plan covers 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. Chiropractic Services have a $20 copay, Physician Specialist Services have a $30 copay, Occupational Therapy Services have a $35 copay, and Physical Therapy and Speech-Language Pathology Services have a $35 copay. Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a minimum copay of $15 and a maximum copay of $15 for individual sessions, and a minimum copay of $10 and a maximum copay of $10 for group sessions. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, annual physical exams, and additional preventive services that require prior authorization and a doctor referral, with Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) having a copay between $0 and $35. The plan does not cover 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, or Counseling Services. The plan also covers Kidney Disease Education Services, and other preventive services, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
Hearing services include hearing exams with a $20 copay, routine hearing exams, and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Essence Advantage Select (HMO) plan covers vision services, including eye exams with a $30 copay and eyewear with a combined maximum benefit of $200 every year. Eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are covered with one pair of each allowed every year. Contact lenses are covered with one pair allowed every year, and upgrades are not covered.
Dental Services See details
Dental Services offers coverage for oral exams with a $30 copay, dental x-rays, and prophylaxis (cleaning) with no copay, and other services with a $4,000 annual maximum. Prosthodontics, fixed has 25% coinsurance. Some services such as Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Essence Advantage Select (HMO) plan. For Medicare Part B Insulin Drugs, there is a $35 copay, and the coinsurance ranges from 0% to 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Select (HMO) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical equipment is covered by Essence Advantage Select (HMO), including Durable Medical Equipment with 20% coinsurance and Prosthetic Devices with 20% coinsurance, but Durable Medical Equipment for use outside the home is not covered. Diabetic Therapeutic Shoes/Inserts are covered with 20% coinsurance, while 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, as well as diagnostic radiological services with a copay up to $200, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $20 copay. Lab services are not covered.
Home Health Services See details
Home Health Services are covered 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 Select (HMO) plan. No copay or coinsurance information is available for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Essence Advantage Select (HMO) plan with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $170.
Other Services See details
The Essence Advantage Select (HMO) plan covers Over-the-Counter (OTC) Items, with a maximum benefit coverage amount of $40.00 every three months, and also provides Nicotine Replacement Therapy (NRT) and Naloxone coverage. Other services, including acupuncture and meal benefits, are not covered.
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