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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 Boone and Callaway Counties. 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 $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 a $295 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For drugs in the preferred generic tier, you will pay a $3 copay at a preferred pharmacy and a $12 copay at a standard pharmacy. For preferred brand drugs, you will pay 46% coinsurance at either pharmacy. After your total drug costs reach $2000, you will enter the catastrophic coverage phase, and you pay nothing for covered drugs.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays. Emergency, primary care, preventive, hearing, vision, and dental services are also included, often with copays. This plan also covers home health, skilled nursing, and cardiac rehabilitation services. This plan provides coverage for ambulance, diagnostic, and radiological services, with specific copays or coinsurance amounts. It also offers coverage for hearing aids, vision eyewear, and dental services up to set maximums. However, certain services like acupuncture, over-the-counter items, and private duty nursing are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute, you pay a $290 copay for days 1-4, and no copay for days 5-90; for Inpatient Hospital Psychiatric, you pay a $300 copay for days 1-5, and no copay for days 6-90. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are covered, but non-Medicare-covered stays and upgrades are not covered for Inpatient Hospital-Acute, and non-Medicare-covered stays are not covered for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services and observation services, have a $250 copay. Ambulatory Surgical Center (ASC) Services have a $240 copay, while Individual and Group Sessions for Outpatient Substance Abuse have copays between $10 and $15. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage Choice (PPO) plan with a $45 copay, and prior authorization is required.
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, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered by the Essence Advantage Choice (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services has a $45 copay, and Worldwide Urgent Coverage has a $110 copay; all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Choice (PPO) plan covers 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. Chiropractic services have a $20 copay, physician specialist services have a $30 copay, individual sessions for mental health and psychiatric services have a $15 copay, group sessions for mental health and psychiatric services have a $10 copay, occupational therapy services have a $40 copay, physical therapy and speech-language pathology services have a $40 copay, and the minimum copay for opioid treatment services is $15.
Preventive Services See details
The Essence Advantage Choice (PPO) plan covers preventive services, including Medicare-covered services, annual physical exams, and additional preventive services with a copay for some services such as Remote Access Technologies ranging from $0 to $40. Additionally, this plan covers Fitness Benefits, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKGs following the Welcome Visit. However, Health Education, In-Home Safety Assessments, Personal Emergency Response Systems, Medical Nutrition Therapy, and other services are not covered.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $20 copay and prescription hearing aids, with a maximum plan benefit of $1000 every two years, while OTC hearing aids and prescription hearing aids for the inner and outer ear are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $30 copay, and eyewear with a combined maximum benefit of $200 every year, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Upgrades are not covered.
Dental Services See details
Dental services include a $30 copay for Medicare dental services and are covered up to a maximum of $1,420 per year for both in-network and out-of-network services. Other services such as 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 are covered, with no copay or coinsurance.
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 ranges from 0% to 20%. For Medicare Part B chemotherapy/radiation drugs and other Medicare Part B drugs, coinsurance ranges from 0% to 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 is covered by the Essence Advantage Choice (PPO) plan, but Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. For Durable Medical Equipment, you will pay 20% coinsurance and there is no copay. For Prosthetic Devices, you will pay 20% coinsurance, and for Medical Supplies you will pay 20% coinsurance. For Diabetic Therapeutic Shoes/Inserts, you will pay 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay between $0 and $30, and Diagnostic Radiological Services with a copay up to $200. Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $15 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 plan does not cover 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. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Essence Advantage Choice (PPO) plan, but require prior authorization. You will have 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, 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 for these services.
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