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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 2025, 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 Chicago 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 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3250.00 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) plan has no deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays depending on the drug tier and pharmacy, such as $3 for preferred generic drugs at a preferred pharmacy and $45 for standard generic drugs at a preferred pharmacy. For non-preferred drugs, you'll pay 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for your Medicare Part D covered drugs.
Additional Benefits
The Essence Advantage Select (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, with the amount depending on the type of care and the length of stay, while outpatient services and emergency services have fixed copays. Primary care, vision, and dental services are covered, each with their own copays and limitations. This plan also covers home health services, skilled nursing facility stays, and dialysis with specific cost-sharing arrangements. Hearing aids, medical equipment, and diagnostic services are included, but additional services like cardiac rehabilitation and certain other services are not covered.
Inpatient Hospital See details
Inpatient Hospital services are covered, including acute and psychiatric care. For Inpatient Hospital-Acute, you pay a $195 copay for days 1-5 and no copay for days 6-90; additional days have a 40% coinsurance. For Inpatient Hospital Psychiatric, you pay a $195 copay for days 1-7 and no copay for days 8-90. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services are covered, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a $250 copay, ambulatory surgical center services have a $195 copay, individual outpatient substance abuse sessions have a $25 copay, and group outpatient substance abuse sessions have a $20 copay. Outpatient blood services include a waived deductible of three pints.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage Select (HMO) plan, with a $70 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage Select (HMO) plan. Ground and Air Ambulance Services have a $240 copay, with no coinsurance. 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 Select (HMO) plan. Emergency Services have a $90 copay, and Urgently Needed Services have a $45 copay, with no coinsurance for either. Worldwide Emergency Coverage and Worldwide Urgent Coverage each have a $90 copay, with no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Select (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 $25 copay, mental health specialty services with a minimum $20 and maximum $25 copay, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits, and opioid treatment program services with a $25 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, and additional preventive services, with some services requiring a doctor's referral and prior authorization. Additional services such as Health Education, In-Home Safety Assessment, and others are not covered. Remote Access Technologies have a copay between $0 and $35.
Hearing Services See details
Hearing Services include Routine Hearing Exams with a $20 copay, and Fitting/Evaluation for Hearing Aids with no coinsurance, but only one visit is covered every two years. Prescription Hearing Aids (all types) are covered, with a maximum benefit of $1000 every two years for both ears combined, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, nor are OTC Hearing Aids.
Vision Services See details
Vision services include eye exams with a $25 copay, with routine eye exams covered once per year. Eyewear is covered, with a combined maximum benefit of $200 per year, and includes one pair of contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames per year. Upgrades are not covered.
Dental Services See details
The Essence Advantage Select (HMO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics. Medicare dental services require prior authorization and a doctor referral with a $25 copay, while other dental services have a $2,000 maximum per year.
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 under the Essence Advantage Select (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered, including Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetic Devices with a 20% coinsurance. Diabetic Equipment is covered, but Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay between $0 and $25, but Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $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 Select (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 under the Essence Advantage Select (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 Select (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Other Services, including acupuncture, over-the-counter items, meal benefits, and more are not covered by the Essence Advantage Select (HMO) plan. No authorization or referrals are required for these services.
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