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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 2026, 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 Lexington and Louisville Metropolitan Areas. This plan received an overall rating of 4.5 out of 5 stars in 2026.
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. Additionally, this plan comes with a Part B Premium reduction of $0.60. You must continue to pay paying your reduced 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 $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) Medicare prescription drug plan features an annual drug deductible of $340. Under this plan, you will pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs when using preferred pharmacies or standard mail order. Tier 2 generic drugs are also highly affordable, starting at a $3 copay for a one-month supply at preferred pharmacies and standard mail order. For higher-tier medications, Tier 3 preferred brands require a $45 copay, while Tier 4 non-preferred drugs carry a $95 copay for a one-month supply at preferred pharmacies. Specialty medications in Tier 5 are subject to a 29% coinsurance across preferred, standard, and mail-order options. Choosing standard pharmacies instead of preferred options or mail order will generally result in higher copays for most drug tiers.
Additional Benefits
The Essence Advantage (HMO) plan offers comprehensive medical coverage with predictable costs, featuring no copay or coinsurance for primary care doctor visits and covered preventive services. Specialist visits require a $35 copay, while emergency room visits carry a $150 copay that is waived if you are admitted within 24 hours. For hospital care, inpatient stays require a $325 daily copay for the first five days with no copay thereafter, and outpatient hospital services carry a $280 copay. This plan also includes key dental, vision, and hearing benefits to help lower your out-of-pocket expenses. Preventive and comprehensive dental care, as well as prescription hearing aids, are available with no copay up to annual limits of $1,600 and $2,000 respectively. Routine eye exams require a $35 copay, eyewear is covered with no copay up to a $200 annual maximum, and members receive an over-the-counter item allowance of $40 every three months with no copay.
Inpatient Hospital See details
Essence Advantage (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $325 daily copay for days 1 through 5 and no copay for days 6 and beyond. This benefit is partially covered as prior authorization is required, and upgrades as well as non-Medicare-covered stays are not covered.
Outpatient Services See details
Essence Advantage (HMO) covers outpatient services with no coinsurance, including outpatient hospital and observation services for a $280 copay, and ambulatory surgical center services for a $245 copay. Outpatient substance abuse services require a $15 copay for individual sessions and a $10 copay for group sessions, while outpatient blood services are available with no copay or deductible.
Partial Hospitalization See details
Essence Advantage (HMO) covers partial hospitalization services with a $40.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
Essence Advantage (HMO) covers ground and air ambulance services with a $240 copay and no coinsurance per trip. Transportation services are partially covered, offering up to 20 one-way trips per year to plan-approved locations via bus or subway with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency services are covered by Essence Advantage (HMO) with a $150 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services are covered with a $30 copay and no coinsurance. Worldwide emergency and urgent care are partially covered with a $150 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $35 copay and no coinsurance. Therapy services require a $30 copay, mental health and psychiatric sessions have a $10 to $15 copay, and telehealth benefits range from a $0 to $40 copay, all with no coinsurance. Chiropractic and podiatry services are not covered under this plan.
Preventive Services See details
Preventive Services are partially covered by Essence Advantage (HMO) with no copay and no coinsurance for covered services, including annual physical exams, kidney disease education, glaucoma screenings, diabetes self-management, and a physical and memory fitness benefit. Sub-services that are not covered under this plan include health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, remote access, home safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by Essence Advantage (HMO) with no deductible, offering routine hearing exams and fitting evaluations for a $20 copay and no coinsurance. Prescription hearing aids are covered with no copay or coinsurance up to a $2,000 annual limit, but OTC hearing aids and inner ear, outer ear, or over the ear prescription hearing aids are not covered.
Vision Services See details
Essence Advantage (HMO) partially covers vision services, offering one routine eye exam per year with a $35 copay and no coinsurance, though a referral is required and other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 annual maximum for one pair of contacts or eyeglasses, but upgrades are not covered.
Dental Services See details
Essence Advantage (HMO) partially covers dental services, offering Medicare-covered dental care for a $35 copay and no coinsurance, and other preventive and comprehensive dental benefits with no copay and no coinsurance up to a $1,600 annual limit. Other diagnostic and other preventive dental services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Essence Advantage (HMO) with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, carry a 0% to 20% coinsurance, with insulin drugs also requiring a $35 copay.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Essence Advantage (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic therapeutic shoes, with no copay and 20% coinsurance, though prior authorization is required. This benefit is partially covered, as diabetic supplies are not covered by the plan.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Essence Advantage (HMO), requiring prior authorization, though lab services are not covered. Diagnostic procedures and tests have no coinsurance and a copay of up to $45, while radiological services feature no copay for diagnostic imaging, a $20 copay for outpatient X-rays, and a 20% coinsurance for therapeutic services.
Home Health Services See details
Essence Advantage (HMO) covers Home Health Services with no copay and no coinsurance, although a referral is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Essence Advantage (HMO) with no coinsurance and a referral requirement, but only some services are covered in practice. Specifically, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered, despite having a listed $15 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Essence Advantage (HMO) with no coinsurance and do not require a prior three-day hospital stay, though prior authorization is required. There is no copay for days 1 through 20, a $188 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services under the Essence Advantage (HMO) plan are partially covered, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $40 every three months. Acupuncture and meal benefits are not covered under this plan.
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