A non-government entity
Essence Advantage Choice Plus (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage Choice Plus (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 Plus (PPO) in 2025, please refer to our full plan details page.
Essence Advantage Choice Plus (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 Plus (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 Plus (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 Plus (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $47.00. 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 $5900.00 (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 $5900.00 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 Plus (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 Plus (PPO) plan has an enhanced alternative drug benefit. The plan has no deductible. In the initial coverage phase, you'll pay a copay for your prescriptions, which varies depending on the drug tier and the pharmacy you use. For example, a preferred generic drug has a $3 copay at a preferred pharmacy. Once your total drug costs reach $2000, you enter the next coverage phase. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Essence Advantage Choice Plus (PPO) plan offers a range of benefits, including inpatient hospital stays with varying copays based on the type and length of stay, and outpatient services that have copays for various services. Emergency services have a $110 copay, and primary care, vision, and dental services are covered with copays ranging from $20 to $35. The plan also covers hearing services with copays and offers hearing aid coverage. Additionally, this plan covers home health services with no copay, and skilled nursing facility services with a copay after the first 20 days. However, some services like cardiac rehabilitation, and some other services are not covered by this plan.
Inpatient Hospital See details
Inpatient Hospital coverage under the Essence Advantage Choice Plus (PPO) plan includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $275 copay for days 1-4, and no copay for days 5-90. For Inpatient Hospital Psychiatric, you pay a $295 copay for days 1-6, and no copay for days 7-90. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric 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 are covered, including outpatient hospital services with a $240 copay, observation services with a $240 copay, and ambulatory surgical center (ASC) services with a $180 copay. Outpatient substance abuse services are partially covered, with individual and group sessions not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Essence Advantage Choice Plus (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 under the Essence Advantage Choice Plus (PPO) plan, with a $250 copay for both ground and air ambulance services. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Essence Advantage Choice Plus (PPO) plan, with a $110 copay and no coinsurance; the copay is waived if admitted to the hospital within 24 hours. Urgently Needed Services have a $40 copay and no coinsurance. Worldwide Emergency Services are covered, including Worldwide Emergency Coverage and Worldwide Urgent Coverage, each with a $110 copay and no coinsurance, but Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Choice Plus (PPO) plan covers primary care physician services, 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 does not cover routine chiropractic care, individual and group sessions for mental health specialty services, podiatry services, individual and group sessions for psychiatric services.
Preventive Services See details
Preventive services are covered, including services not usually covered by Medicare, and include a fitness benefit. Remote Access Technologies have a copay between $0 and $35, and other preventive services are not covered, including health education, in-home safety assessments, personal emergency response systems, and more.
Hearing Services See details
Hearing Services are covered, including routine hearing exams with a $20 copay, and fitting/evaluation for hearing aids with a copay of $20. Prescription hearing aids (all types) are covered up to $2000 every two years. Prescription hearing aids for the inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $30 copay, and for eyewear with a combined maximum benefit of $200 every year. Contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are also covered, but upgrades are not covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $30 copay. Other Dental Services, including oral exams, dental x-rays, and other preventive services, are covered up to a maximum of $3,500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Essence Advantage Choice Plus (PPO) plan. Medicare Part B Insulin Drugs have a $35 copay, and the coinsurance ranges from 0% to 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance that ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Choice Plus (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical equipment is covered by the Essence Advantage Choice Plus (PPO) plan, with a 20% coinsurance for durable medical equipment, prosthetic devices, medical supplies, and diabetic therapeutic shoes/inserts; durable medical equipment for use outside the home and diabetic supplies are not covered. There is no copay for any of these services.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and tests with a copay between $0 and $30, but Lab Services are not covered. Radiological services are covered, with diagnostic services having a copay of up to $200, therapeutic services having 20% coinsurance, and outpatient X-rays having a $15 copay.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Choice Plus (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 Plus (PPO) plan. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization required. There is no copay for days 1-20, and a $170 copay per day for days 21-100.
Other Services See details
Other Services are not covered by the Essence Advantage Choice Plus (PPO) plan, including acupuncture, over-the-counter items, meal benefits, and many other services. No authorization or referral is required for additional services.
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