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Essence Advantage Empower (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage Empower (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Advantage Empower (HMO) in 2025, please refer to our full plan details page.
Essence Advantage Empower (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 Empower (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 Empower (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 Empower (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 Empower (HMO) plan has a $295 deductible for prescription drugs. After the deductible, you will pay a copay for your prescriptions. For preferred generic drugs, the copay is $3 at a preferred pharmacy and $12 at a standard pharmacy. For standard generic drugs, the copay is $45 at a preferred pharmacy and $47 at a standard pharmacy. Preferred brand drugs have a copay of $75 at a preferred pharmacy and $100 at a standard pharmacy. Non-preferred drugs have a 29% coinsurance. The plan has no copay for specialty tier drugs.
Additional Benefits
The Essence Advantage Empower (HMO) plan offers a range of benefits, including coverage for inpatient hospital stays with copays, outpatient services, and ambulance services. Emergency services, hearing exams, and vision services are also covered, with specific copays for each. Dental services, home infusion, dialysis, and medical equipment are included with varying cost-sharing amounts such as copays and coinsurance. Additionally, this plan provides coverage for primary care, preventive services, and skilled nursing facility services with copays or no cost-sharing. Other covered services include home health, diagnostic and radiological services, and over-the-counter items up to a certain amount. However, some services like cardiac rehabilitation and additional home health services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you pay a $250 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you pay a $260 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital-Acute and Additional Days for Inpatient Hospital Psychiatric are covered. Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered with a $300 copay. Ambulatory Surgical Center (ASC) Services are covered with a $175 copay, and Outpatient Substance Abuse Services, including individual and group sessions, have copays ranging from $10 to $15. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage Empower (HMO) plan. Ground and air ambulance services have a $220 copay, with no coinsurance. However, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Essence Advantage Empower (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, and Urgently Needed Services have a $40 copay, with no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Empower (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, and mental health specialty services with a $15 copay for individual sessions and a $10 copay for group sessions. Physical therapy and speech-language pathology services have a $35 copay, and opioid treatment program services have a $15 minimum copay. However, 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 other services that may require a doctor's referral. Additional preventive services include a Remote Access Technologies benefit with a copay between $0 and $35. 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, and Counseling Services are not covered.
Hearing Services See details
The Essence Advantage Empower (HMO) plan covers hearing exams with a $20 copay, and fitting/evaluation for hearing aids. Prescription hearing aids are covered up to $1,000 every two years, with a limit of two hearing aids every two years. OTC hearing aids and prescription hearing aids for the inner and outer ear are not covered.
Vision Services See details
The Essence Advantage Empower (HMO) plan covers eye exams with a $35 copay, and routine eye exams are covered once per year. This plan also covers eyewear, including contact lenses (1 pair per year), eyeglasses (lenses and frames, 1 pair per year), eyeglass lenses (1 pair per year), and eyeglass frames (1 frame per year), with a combined maximum benefit of $200 per year. Upgrades are not covered.
Dental Services See details
The Essence Advantage Empower (HMO) plan covers dental services, including oral exams with a $35 copay, dental x-rays, prophylaxis (cleaning) and fluoride treatment. Orthodontic services are covered up to a maximum of $1000 per year, while restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are also covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay, and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Empower (HMO) plan. There is a 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment is covered by the Essence Advantage Empower (HMO) plan, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices with 20% coinsurance. Diabetic Therapeutic Shoes/Inserts are covered with 20% coinsurance, while Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $30, while Diagnostic Radiological Services have a copay up to $200. Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $20 copay. Lab services are not covered.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Empower (HMO) plan 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 Empower (HMO) plan. This includes 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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Essence Advantage Empower (HMO) plan, but require prior authorization. You will have no copay for days 1-20, and a $170 copay for days 21-100; additional and non-Medicare-covered SNF days are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items, with a maximum benefit of $40 every three months, and nicotine replacement therapy is offered. Acupuncture, meal benefits, dual eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, and other services are not covered.
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