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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 2026, 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 2026.
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 $3600.00 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) Medicare plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately. Beneficiaries pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs when using a preferred pharmacy or standard mail order. Tier 2 generic drugs are also highly affordable, requiring just a $3 copay for a one-month supply at preferred pharmacies. For higher-tier medications, Tier 3 preferred brands carry a $45 copay and Tier 4 non-preferred drugs carry a $95 copay at preferred pharmacies, though standard pharmacy copays are slightly higher. Tier 5 specialty drugs require a 33% coinsurance for a one-month supply at all participating pharmacies. Choosing standard mail order can also lower your costs for three-month supplies of Tier 2, Tier 3, and Tier 4 drugs.
Additional Benefits
The Essence Advantage Select (HMO) plan offers affordable healthcare coverage with no copay for primary care physician visits and a $25 copay for specialist consultations. For hospital stays, inpatient care requires a $245 daily copay for the first seven days and no copay for days eight through 90, while emergency room visits carry a $125 copay. Essential preventive services, including annual physical exams and fitness benefits, are also fully covered with no copay or coinsurance. This plan also includes valuable extra benefits, such as dental coverage with no copay for preventive and comprehensive care, alongside an orthodontic benefit up to a $2,000 annual limit. For vision and hearing, members pay a $25 copay for routine eye exams with a $200 annual eyewear allowance, and a $20 copay for hearing exams with a $1,000 prescription hearing aid allowance every two years. Additionally, the plan features an over-the-counter allowance of up to $40 quarterly with no copay.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Essence Advantage Select (HMO), excluding upgrades and non-Medicare-covered stays. Covered acute and psychiatric stays require a $245 daily copay for days 1 to 7, no copay for days 8 to 90, and no coinsurance, though additional acute days beyond day 90 incur a 40% coinsurance.
Outpatient Services See details
Essence Advantage Select (HMO) covers outpatient services with no coinsurance, featuring a $325 copay for outpatient hospital and observation services and a $225 copay for ambulatory surgical center services. Outpatient substance abuse services require a $25 copay for individual sessions and a $20 copay for group sessions, while outpatient blood services are covered with no copay and no deductible.
Partial Hospitalization See details
Essence Advantage Select (HMO) covers partial hospitalization services with a $70 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Essence Advantage Select (HMO) covers ground and air ambulance services with a $240 copay and no coinsurance, subject to prior authorization. Transportation services to plan-approved or any health-related locations are not covered under this plan.
Emergency Services See details
Essence Advantage Select (HMO) covers emergency services with a $125 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $45 copay and no coinsurance. Worldwide emergency services are partially covered with a $125 copay and no coinsurance for emergency and urgent care, but worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage Select (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $25 copay and no coinsurance. Therapy services cost a $35 copay with no coinsurance, mental health and psychiatric services range from a $20 to $25 copay with no coinsurance, and podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Essence Advantage Select (HMO) with no copay and no coinsurance for covered services such as annual physical exams, kidney disease education, and fitness benefits. However, the plan does not cover several sub-services, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, remote access, home modifications, and counseling.
Hearing Services See details
Hearing services are covered by Essence Advantage Select (HMO), which offers routine exams and fitting evaluations for a $20 copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $1,000 maximum every two years, but over-the-counter (OTC) hearing aids, as well as inner ear, outer ear, and over the ear prescription aids, are not covered.
Vision Services See details
Essence Advantage Select (HMO) offers vision services with no deductibles, featuring a $25 copay and no coinsurance for an annual routine eye exam, though other eye exam services are not covered. Covered eyewear has no copay and no coinsurance up to a $200 annual limit for one pair of eyeglasses or contacts, but upgrades are not covered.
Dental Services See details
Dental services are partially covered by Essence Advantage Select (HMO), featuring a $25 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for covered preventive and comprehensive care. While other diagnostic and other preventive services are not covered, orthodontic services are covered up to a $2,000 annual maximum, and comprehensive options like implants and endodontics are unlimited with no copay or coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Essence Advantage Select (HMO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin requires a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Essence Advantage Select (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Essence Advantage Select (HMO) partially covers medical equipment with no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts. Prior authorization is required for these covered services, while diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by Essence Advantage Select (HMO), as lab services are not covered and prior authorization is required. Covered diagnostic procedures feature no coinsurance and a copay of up to $40, while radiological services cost a $20 copay for X-rays, a 20% coinsurance for therapeutic radiology, and no copay for diagnostic radiology.
Home Health Services See details
Home health services are covered by Essence Advantage Select (HMO) with no copay and no coinsurance, though a referral is required to receive care.
Cardiac Rehabilitation Services See details
Essence Advantage Select (HMO) offers cardiac rehabilitation services with no coinsurance, but only some services are covered because cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $20 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Essence Advantage Select (HMO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. You will pay no copay for days 1 through 20 and a $214 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Essence Advantage Select (HMO) partially covers Other Services, offering no copay and no coinsurance for Over-the-Counter (OTC) items up to a $40 quarterly reimbursement limit. Acupuncture, meal benefits, and other additional services are not covered under this benefit.
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