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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 St. Louis Metropolitan Area. This plan received an overall rating of 4 out of 5 stars in 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 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 combined Maximum Out-Of-Pocket cost of $6200.00 (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 $6200.00 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. The plan has a $295 deductible for prescription drugs. In the initial coverage phase, after you meet your deductible, you will pay a copay for your prescriptions, depending on the drug tier and pharmacy. For example, preferred generic drugs have a $3 copay at a preferred pharmacy, while standard generic drugs have a $47 copay. Once your total drug costs reach $2000, you enter the next coverage phase.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers a wide array of benefits. This plan covers inpatient hospital stays with a copay, outpatient services with varying copays, and emergency services with a copay. It also includes coverage for primary care, preventive, hearing, vision, dental, and home infusion bundled services. Additional benefits include coverage for ambulance, dialysis, medical equipment, diagnostic, home health, cardiac rehabilitation, and skilled nursing facility services. There are also some services that are not covered, such as certain mental health services, and other services like acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $275 for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute, and a copay of $300 for days 1-5 and no copay for days 6-90 for Inpatient Hospital Psychiatric. Additional days for both services are covered. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services and observation services, are covered with a $300 copay, while Ambulatory Surgical Center (ASC) Services have a $180 copay. Outpatient Substance Abuse Services are not covered, and Outpatient Blood Services are covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Essence Advantage Choice (PPO) plan, with a $45 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage Choice (PPO) plan. Ground and Air Ambulance Services have a $270 copay, and there is 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 under the Essence Advantage Choice (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, and Urgently Needed Services have a $40 copay; all three have no coinsurance. Worldwide Urgent Coverage is covered with a $140 copay, and Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic services have a $20 copay, while Occupational Therapy, Physician Specialist, Other Health Care Professional, and Physical Therapy/Speech-Language Pathology Services have a $40 copay. Individual and group sessions for Mental Health and Psychiatric services are not covered, and Routine Chiropractic Care is not covered. Podiatry Services are not covered.
Preventive Services See details
The Essence Advantage Choice (PPO) plan covers preventive services, including Medicare-covered services, annual physical exams, and other preventive services with a copay for remote access technologies ranging from $0 to $40. Additional services like health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing services with the Essence Advantage Choice (PPO) plan include coverage for hearing exams with a $20 copay, and prescription hearing aids up to $1,000 every two years. OTC hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, and prescription hearing aids - over the ear are not covered.
Vision Services See details
The Essence Advantage Choice (PPO) plan covers vision services, including eye exams with a $40 copay. Eyewear is covered with a combined maximum benefit of $200 every year for both in and out-of-network services, and contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered. Upgrades are not covered.
Dental Services See details
Dental services are covered under the Essence Advantage Choice (PPO) plan, with a $40 copay for Medicare Dental Services. Other dental services include 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, all of which are covered, and the plan has a maximum benefit coverage of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage Choice (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits under the Essence Advantage Choice (PPO) plan include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with no copay and coinsurance for Medicare-covered devices and supplies, and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with some services requiring prior authorization. Diagnostic Procedures/Tests have a copay between $0 and $30, while Lab Services are not covered. Diagnostic Radiological Services have a copay up to $200, and Therapeutic Radiological Services have 20% coinsurance. Outpatient X-Ray Services have a $25 copay.
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 covered, but the specific services of 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 are not covered. This benefit requires prior authorization, and copay information is available in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Essence Advantage Choice (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $170.
Other Services See details
Other Services are not covered by the Essence Advantage Choice (PPO) plan, including 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. No authorization or referrals are required.
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