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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 2026, 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 and Mid Missouri. This plan received an overall rating of 4.5 out of 5 stars in 2026.
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 $340.00 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) prescription drug plan features an annual drug deductible of $340. You will pay no copay for Tier 1 preferred generic drugs at preferred pharmacies and through standard mail order, and Tier 6 select care drugs also feature no copay across all pharmacies. For Tier 2 generic medications, copays are as low as $3 for a one-month supply at preferred pharmacies and standard mail order. Higher-tier medications require copayments or coinsurance, with Tier 3 preferred brands starting at a $45 copay and Tier 4 non-preferred drugs starting at a $75 copay for a one-month supply. Standard pharmacies charge slightly higher copays, such as $47 for Tier 3 and $100 for Tier 4 one-month supplies. Specialty prescription drugs in Tier 5 require a 29% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The Essence Advantage Select (HMO) plan offers robust medical coverage with no copay for primary care visits, preventive services, home health care, and partial hospitalization. For more intensive care, members will pay a $30 copay for specialists, a $150 copay for emergency services, and a $240 daily copay for the first seven days of inpatient hospital stays. Major medical equipment, dialysis, and therapeutic radiology services generally require a 20% coinsurance with no copay. This plan also includes valuable supplemental benefits, featuring preventive and comprehensive dental care with no copay up to a generous $2,900 annual limit. Additionally, members benefit from hearing and vision coverage, which includes a $1,000 hearing aid allowance every two years and a $200 yearly limit for eyewear. A quarterly over-the-counter reimbursement of up to $40 is also available with no copay to help cover everyday health and wellness items.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Essence Advantage Select (HMO) with no coinsurance and a copay of $240 per day for days 1 through 7, followed by no copay for days 8 and beyond for acute and psychiatric stays. Prior authorization is required, and upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Essence Advantage Select (HMO) covers outpatient hospital and observation services with a $325 copay and no coinsurance, and ambulatory surgical center services with a $175 copay and no coinsurance. Outpatient substance abuse services have no coinsurance and a copay of $15 for individual or $10 for group sessions, while outpatient blood services require no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Essence Advantage Select (HMO) with no copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Essence Advantage Select (HMO) with a $220 copay and no coinsurance for both ground and air ambulance services, which require prior authorization. Although some transportation services are covered, transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
Essence Advantage Select (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a $35 copay and no coinsurance. Worldwide emergency services are partially covered with a $150 copay and no coinsurance for worldwide emergency and urgent care, but worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits are partially covered by the Essence Advantage Select (HMO) plan, which excludes podiatry and chiropractic services. Covered services require no coinsurance and include primary care physician visits with no copay, specialist visits for a $30 copay, physical and occupational therapy for a $35 copay, and mental health sessions for a $10 to $15 copay.
Preventive Services See details
Preventive Services are partially covered by Essence Advantage Select (HMO) with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and diabetes self-management training. While physical and memory fitness benefits are covered, several additional services are not covered, including health education, personal emergency response systems, medical nutrition therapy, in-home safety assessments, and alternative therapies.
Hearing Services See details
Essence Advantage Select (HMO) partially covers hearing services with no deductible, offering hearing exams for a $20 copay and no coinsurance, though a referral is required. Prescription hearing aids are covered with no copay and no coinsurance up to a $1,000 maximum every two years, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by Essence Advantage Select (HMO), offering one annual routine eye exam with a $30 copay and no coinsurance, while other eye exam services are not covered. Eyewear is also partially covered with no copay or coinsurance up to a $200 yearly limit, though upgrades are not covered.
Dental Services See details
Essence Advantage Select (HMO) provides partially covered dental services, including Medicare-covered dental with a $30 copay and no coinsurance, and preventive and comprehensive services with no copay and no coinsurance up to a $2,900 annual maximum. Other diagnostic and other preventive dental services are not covered.
Home Infusion bundled Services See details
Essence Advantage Select (HMO) covers Home Infusion bundled Services with no copay and no coinsurance, although prior authorization is required. Under this plan, Medicare Part B chemotherapy, radiation, and other Part B drugs have no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Essence Advantage Select (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Essence Advantage Select (HMO) covers durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes and inserts with no copay and 20% coinsurance, though prior authorization is required. Diabetic equipment is partially covered by the plan, as diabetic supplies are not covered and coverage is limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by Essence Advantage Select (HMO), as lab services are not covered. Covered diagnostic procedures and tests require prior authorization and carry no coinsurance with a copay ranging from $0 to $30, while radiological services require prior authorization and range from no copay for diagnostic radiology, a $20 copay for X-rays, and 20% coinsurance for therapeutic radiology.
Home Health Services See details
Essence Advantage Select (HMO) covers Home Health Services with no copay and no coinsurance, although a referral is required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Essence Advantage Select (HMO) with no coinsurance and a referral requirement, meaning some services are covered. However, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered and require a $20 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Essence Advantage Select (HMO) with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a daily copay of $170 for days 21 through 100; additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Essence Advantage Select (HMO), which provides 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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