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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 Lexington and Louisville Metropolitan Areas. 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 the deductible, you will pay a copay for your prescriptions depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $3 copay at a preferred pharmacy, while standard generic drugs have a $45 copay at a preferred pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Essence Advantage (HMO) plan offers a variety of health benefits. Inpatient hospital stays have copays ranging from $275 to $295, depending on the type of care and the length of stay. Outpatient services, including mental health and substance abuse services, have varying copays, and emergency services have a $110 copay. This plan also covers primary care, hearing, vision, and dental services, each with specific copays and annual limits. Additional benefits include home health services with no copay, skilled nursing facility stays, and coverage for medical equipment and diagnostic services, each with either a copay or coinsurance. The plan also provides an over-the-counter (OTC) benefit of $40 every three months.
Inpatient Hospital See details
Inpatient Hospital services are covered under the Essence Advantage (HMO) plan. For Inpatient Hospital-Acute, you will pay a copay of $295 for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will pay a copay of $275 for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient Services with the Essence Advantage (HMO) plan include coverage for outpatient hospital services, observation services, and ambulatory surgical center (ASC) services, each with a $280, $280, and $245 copay, respectively. Outpatient substance abuse services include individual sessions with a copay of $15 and group sessions with a copay of $10. Outpatient blood services are also covered.
Partial Hospitalization See details
Essence Advantage (HMO) covers partial hospitalization with a $40 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage (HMO) plan. Ground and air ambulance services each have a $240 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, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered by the Essence Advantage (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services have a $30 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 $30 copay, and physician specialist services with a $35 copay. Mental health specialty services, including individual sessions with a $15 copay and group sessions with a $10 copay, are also covered, as are physical therapy and speech-language pathology services with a $30 copay. The plan also covers additional telehealth benefits and opioid treatment program services with a minimum copay of $15 and a maximum copay of $15. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, as well as annual physical exams. Additional preventive services require prior authorization and a doctor referral, and may have a copay.
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 are covered, with a maximum benefit of $2,000 every year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision services include eye exams with a $35 copay, and eyewear including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames, with a combined maximum benefit of $200 every year. Upgrades are not covered.
Dental Services See details
The Essence Advantage (HMO) plan covers dental services, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments, with specific limits on the number of visits per year. Medicare Dental Services require prior authorization and a doctor referral with a $35 copay, and orthodontic services are covered up to a maximum of $750 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage (HMO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical equipment is covered under the Essence Advantage (HMO) plan, including Durable Medical Equipment (DME) with a 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance; however, 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, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $30, while Lab Services are not covered. Diagnostic Radiological Services have a copay up to $200 and Therapeutic Radiological Services have a 20% coinsurance. 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. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
For the Essence Advantage (HMO) plan, Cardiac Rehabilitation Services are not covered. A doctor referral is required.
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 $188.
Other Services See details
The Essence Advantage (HMO) plan does not cover acupuncture, meal benefits, or services for those with mental disabilities, but it does offer over-the-counter (OTC) items with a $40 benefit every three months, including nicotine replacement therapy. All other services are not covered.
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