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Essence Advantage Choice (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage Choice (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Advantage Choice (PPO) in 2025, please refer to our full plan details page.
Essence Advantage Choice (PPO) is a PPO 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 Choice (PPO) 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 Choice (PPO).
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 Choice (PPO), 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 combined Maximum Out-Of-Pocket cost of $6900.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Choice (PPO) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs with this plan. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have a $3 copay at preferred pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you will pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers a wide range of benefits with varying cost-sharing. Inpatient hospital stays have a $375 copay for the first 5 days, and then no copay for days 6-90. Outpatient services have copays ranging from $10 to $325, while primary care, preventive, and home health services have no copay. Additional benefits include coverage for hearing, vision, and dental services, with copays and maximum benefits. The plan also covers ambulance, emergency, and partial hospitalization services with specific copays. Some services like home infusion and medical equipment have coinsurance, while others, such as cardiac rehabilitation, are not covered.
Inpatient Hospital See details
Inpatient hospital services are covered, including acute and psychiatric care. For days 1-5 of acute or psychiatric care, the copay is $375, and there is no copay for days 6-90. Additional days for both acute and psychiatric care are covered, while non-Medicare covered stays and upgrades are not covered for acute care, and non-Medicare covered stays are not covered for psychiatric care.
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 $325 copay, ambulatory surgical center services have a $285 copay, individual outpatient substance abuse sessions have a $15 copay, and group outpatient substance abuse sessions have a $10 copay. Outpatient blood services also have a waived deductible for three pints.
Partial Hospitalization See details
Partial Hospitalization is covered under the Essence Advantage Choice (PPO) plan, with a $45 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Essence Advantage Choice (PPO) plan. Ground and air ambulance services have a copay of $290, with no coinsurance, and 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 Choice (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $45 copay; all three have no coinsurance. Worldwide Urgent Coverage also has a $125 copay, and Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Choice (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, physician specialist services with a $30 copay, and physical therapy and speech-language pathology services with a $35 copay. The plan also covers individual and group sessions for mental health and psychiatric services with copays ranging from $10 to $15, and opioid treatment program services with a $15 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Essence Advantage Choice (PPO) covers preventive services, including Medicare-covered services, annual physical exams, and additional preventive services. The plan also covers remote access technologies with a copay between $0 and $35, and a fitness benefit including physical and memory fitness.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $20 copay, and fitting/evaluation for hearing aids. Prescription hearing aids are covered up to $1000 per year, but inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $30 copay, and eyewear with a combined maximum benefit of $200 per year. Contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are also covered, and upgrades are not covered.
Dental Services See details
Dental services are covered, with a $30 copay for Medicare dental services. Other dental services have a maximum plan benefit of $1000 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 coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Choice (PPO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered under the Essence Advantage Choice (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, but Durable Medical Equipment for use outside the home is not covered. Prosthetic devices and medical supplies have a 20% coinsurance, while Diabetic Equipment is covered, but 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, including Diagnostic Procedures/Tests with a copay between $0 and $30, and Diagnostic Radiological Services with a copay up to $200. Outpatient X-Ray Services have a $30 copay, and Therapeutic Radiological Services have a 20% coinsurance, while Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Choice (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Essence Advantage Choice (PPO) 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 Choice (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $184 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services are not covered by the Essence Advantage Choice (PPO) plan. Specifically, acupuncture, over-the-counter items, 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 are not covered.
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