A non-government entity
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 2026, 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 and Mid Missouri. This plan received an overall rating of 3 out of 5 stars in 2026.
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 $340.00 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 $7400.00 (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 $7400.00 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:
Sign up for Essence Advantage Choice (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Essence Advantage Choice (PPO) plan features an annual drug deductible of $340. For Tier 1 preferred generic drugs, you will pay no copay at preferred pharmacies or through standard mail order, while standard pharmacies charge a $4 copay for a one-month supply. Tier 2 generic drugs cost a low $5 copay for a one-month supply at preferred pharmacies and standard mail order, compared to a $12 copay at standard pharmacies. Tier 3 preferred brand drugs require a $47 copay for a one-month supply across preferred pharmacies, standard pharmacies, and standard mail order. For higher-tier medications, Tier 4 non-preferred drugs carry a 50% coinsurance, while Tier 5 specialty drugs require a 29% coinsurance for a one-month supply.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care doctor visits, home health services, and routine preventive care. For specialized care, members pay a $40 copay for specialist visits and a $330 daily copay for the first seven days of inpatient hospital stays, with no copay required for subsequent days. Outpatient hospital services generally carry a $395 copay, while emergency room visits require a $130 copay that is waived if admitted. This plan also includes valuable supplemental benefits, such as dental services with no copay up to an annual maximum of $1,840 and routine hearing exams for a $20 copay. Prescription hearing aids and routine eyewear are covered with no copay up to generous plan limits, though some diagnostic services and medical equipment may require a 20% coinsurance. Overall, this PPO plan provides a balanced cost-sharing structure with clear copays for major services and no coinsurance for many routine care needs.
Inpatient Hospital See details
Essence Advantage Choice (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $330 daily copay for days 1 through 7 and no copay for days 8 and beyond. This benefit is partially covered because hospital upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Essence Advantage Choice (PPO) covers outpatient hospital and observation services with a $395 copay and no coinsurance, and ambulatory surgical center services with a $295 copay and no coinsurance. Outpatient blood services feature no copay or coinsurance, and while some outpatient substance abuse services are covered, individual and group sessions are not covered.
Partial Hospitalization See details
Partial hospitalization is covered by Essence Advantage Choice (PPO) with a $45.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Essence Advantage Choice (PPO) covers ground and air ambulance services with a $270 copay and no coinsurance, though prior authorization is required. While some transportation services are covered, transportation to plan-approved or health-related locations is not covered.
Emergency Services See details
Essence Advantage Choice (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency and urgent care are partially covered with a $130 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage Choice (PPO) offers primary care doctor visits and opioid treatment services with no copay and no coinsurance, while specialist visits and physical, occupational, or speech therapies cost a $40 copay with no coinsurance. Telehealth services are available with a copay ranging from $0 to $45 and no coinsurance, but chiropractic, podiatry, mental health, and psychiatric services are not covered.
Preventive Services See details
Essence Advantage Choice (PPO) offers partially covered preventive services with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and fitness programs. However, several additional preventive services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
Essence Advantage Choice (PPO) covers hearing exams, including 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 limit every two years, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by Essence Advantage Choice (PPO), offering one routine eye exam per year for a $40 copay and no coinsurance, while other eye exams are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 annual maximum, though upgrades are excluded.
Dental Services See details
Dental services are covered by Essence Advantage Choice (PPO), which offers Medicare-covered dental care for a $40 copay and no coinsurance. Other preventive and comprehensive dental services, including exams, cleanings, and implants, have no copay and no coinsurance up to a combined annual maximum benefit of $1,840.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Essence Advantage Choice (PPO) with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs carry a coinsurance of 0% to 20%, while Part B insulin drugs require a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Essence Advantage Choice (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Essence Advantage Choice (PPO) partially covers Medical Equipment with no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts. Diabetic supplies are not covered under this plan, prior authorization is required, and diabetic equipment is limited to specified manufacturers.
Diagnostic and Radiological Services See details
Essence Advantage Choice (PPO) partially covers diagnostic and radiological services, as lab services are not covered. Covered diagnostic procedures and tests require no coinsurance and a copay of $0 to $30, while radiological services require prior authorization and range from no copay for diagnostic radiology to a $25 copay for X-rays and 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home health services are covered under the Essence Advantage Choice (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under the Essence Advantage Choice (PPO) plan require prior authorization and have a $20 copay and no coinsurance, but only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Essence Advantage Choice (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $170 copay for days 21 through 100 per stay, though prior authorization is required. Admission does not require a prior three-day hospital stay, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are not covered under the Essence Advantage Choice (PPO) plan, meaning there is no coverage, copay, or coinsurance for acupuncture, over-the-counter (OTC) items, and meal benefits.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved