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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 OH- Brown Butler Clermont Clinton Hamilton Warren. The overall rating for this plan is not yet available for 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 the deductible is met, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, you will pay a $3 copay at a preferred pharmacy or a $10 copay at a standard pharmacy. For non-preferred drugs, you will pay 29% coinsurance. Once your total drug costs reach $2,000, 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 with varying costs. Inpatient hospital stays have copays that vary depending on the length of stay, while outpatient services, including hospital and ambulatory surgical center services, have copays ranging from $245 to $285. Emergency and primary care services have copays, and many preventive services have no copay. The plan also covers hearing, vision, and dental services, each with specific copays or coverage limits. Additional benefits include home health services with no copay, and coverage for durable medical equipment, prosthetic devices, and diagnostic services, all with coinsurance. The plan also offers coverage for over-the-counter items with a quarterly limit.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a copay of $295 for days 1-5, and no copay for days 6-90; Non-Medicare-covered Stay and Upgrades are not covered. For Inpatient Hospital Psychiatric, you pay a copay of $275 for days 1-6, and no copay for days 7-90; Non-Medicare-covered Stay is not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services and observation services, require a $285 copay. Ambulatory Surgical Center (ASC) services have a $245 copay, while individual and group sessions for outpatient substance abuse have a copay between $10 and $15. Outpatient blood services are also covered, with a waived three-pint deductible.
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. Ground and Air Ambulance Services have a $240 copay, with no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including urgently needed services and worldwide emergency coverage, are covered by the Essence Advantage (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while urgently needed services have a $30 copay; there is no coinsurance for any of these services, and worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage (HMO) covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, physician specialist services, and physical therapy/speech-language pathology services have a $30 copay, and individual/group mental health sessions have copays between $10 and $15.
Preventive Services See details
The Essence Advantage (HMO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams, kidney disease education services, and other preventive services. Additional preventive services require prior authorization and may have a copay, and the plan also covers Remote Access Technologies with a copay between $0 and $30.
Hearing Services See details
Hearing Services include hearing exams with a $20 copay, and Routine Hearing Exams and Fitting/Evaluation for Hearing Aids are covered. Prescription Hearing Aids (all types) are covered, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC Hearing Aids 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, with a combined maximum benefit of $200 per year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare Dental Services with a $30 copay, oral exams (2 visits per year), dental x-rays (1 per year), prophylaxis (cleaning) (2 visits per year), fluoride treatment (1 per year), orthodontic services with a maximum benefit of $750 per year, and other services including restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, both with 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 between 20% and 20%.
Medical Equipment See details
The Essence Advantage (HMO) plan covers Durable Medical Equipment (DME) with 20% coinsurance and requires prior authorization, as well as Prosthetic Devices and Medical Supplies with a 20% coinsurance, while Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a minimum copay of $0 and a maximum copay of $30 for diagnostic procedures/tests, and a copay for Medicare-covered diagnostic and therapeutic radiological services. Therapeutic Radiological Services have a 20% coinsurance, and outpatient X-ray services have a $20 copay.
Home Health Services See details
Home Health Services are covered by Essence Advantage (HMO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD Services are not covered. There is a copay for Cardiac and Pulmonary Rehabilitation Services, but the exact amount is not specified.
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 covers Over-the-Counter (OTC) items with a maximum benefit of $40 every three months, including Nicotine Replacement Therapy and Naloxone. Other services like acupuncture, meal benefits, and several additional services are not covered.
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