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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 Cincinnati Metro Area - Kentucky/Indiana counties. 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 $4600.00 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, your cost will vary depending on the drug tier and the pharmacy you use. In the initial coverage phase, you will pay a copay for prescriptions, which ranges from $3 to $100 depending on the drug tier and pharmacy. For non-preferred drugs, you pay 29% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Essence Advantage (HMO) plan offers a range of benefits. It covers inpatient hospital stays, outpatient services, and emergency services with varying copays. The plan also includes coverage for primary care, preventive services, and home health services with no copay. Additional benefits include coverage for hearing, vision, and dental services, with set copays and annual maximums for specific services. The plan also provides coverage for medical equipment, dialysis, and home infusion services, with coinsurance for some services. However, it's important to note that certain services like cardiac rehabilitation, and many other services are not covered by this plan.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $295 for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute; Inpatient Hospital Psychiatric has a copay of $275 for days 1-6 and no copay for days 7-90. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are covered, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for outpatient hospital services with a $285 copay, observation services with a $285 copay per stay, and ambulatory surgical center services with a $245 copay. The plan also covers outpatient substance abuse services, including individual sessions with a $15 copay and group sessions with a $10 copay, and outpatient blood services.
Partial Hospitalization See details
Essence Advantage (HMO) covers partial hospitalization with a $35 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage (HMO) plan, with prior authorization required for all ambulance services. Ground and Air Ambulance Services have a copay of $240, 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 under the Essence Advantage (HMO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $30 copay, and Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $125 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage (HMO) plan covers primary care physician services, occupational therapy services, physician specialist services, mental health specialty services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, while routine chiropractic care is not covered.
Preventive Services See details
The Essence Advantage (HMO) plan covers preventive services including Medicare-covered services with no copay, and additional preventive services with a copay. Some services like health education, in-home safety assessments, and wigs for hair loss are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $20 copay, and prescription hearing aids (all types) with a maximum benefit of $2,000 every year. Fitting/evaluation for hearing aids is covered for 1 visit every year, and OTC hearing aids, and prescription hearing aids for the inner, outer, and over the ear are not covered.
Vision Services See details
The Essence Advantage (HMO) plan covers vision services including routine eye exams with a $30 copay. The plan also covers eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, with a combined maximum benefit of $200 every year. Upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $30 copay, and other dental services including oral exams, dental x-rays, cleaning, fluoride treatments, orthodontics, restorative services, adjunctive general services, endodontics, periodontics, removable prosthodontics, maxillofacial prosthetics, implant services, fixed prosthodontics, oral and maxillofacial surgery, and orthodontics. Orthodontic services have a maximum benefit of $750 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and between 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with between 0-20% coinsurance. Prior authorization is required for this benefit.
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 benefits for Essence Advantage (HMO) include Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment. For Durable Medical Equipment, there is a 20% coinsurance, but no copay, and Durable Medical Equipment for use outside the home is not covered. For Prosthetics/Medical Supplies, there is a 20% coinsurance, with no copay, and for Diabetic Equipment, there is coinsurance for Medicare-covered Diabetic Supplies, but Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Essence Advantage (HMO) plan. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $30, and Diagnostic Radiological Services have a maximum copay of $200; however, Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the Essence Advantage (HMO) plan with no copay and no coinsurance. However, 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, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. There is a copay for 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, but the cost is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Essence Advantage (HMO) plan, requiring prior authorization. You will have no copay for days 1-20, and a $188 copay per day for days 21-100.
Other Services See details
Under "Other Services", Essence Advantage (HMO) does not cover acupuncture, meal benefits, 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. However, Over-the-Counter (OTC) Items are covered, with a maximum benefit of $40 every three months, including Nicotine Replacement Therapy (NRT) and Naloxone coverage.
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