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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 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 Southwest Missouri and Northwest/Central Arkansas. 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 $6150.00 (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 $6150.00 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 features an Enhanced Alternative drug benefit with a $340 annual prescription drug deductible. During the initial coverage phase, you will pay a $3 copay for Tier 1 preferred generics at preferred pharmacies, while Tier 2 standard generics require a $47 copay. Higher tiers, including Tier 3 preferred brands and Tier 4 non-preferred drugs, require a 50% and 29% coinsurance respectively. If you qualify for the low-income subsidy, also known as Extra Help, your Part D premium is reduced to no cost. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase where you pay nothing for covered Medicare Part D drugs.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers comprehensive medical coverage with predictable cost-sharing, featuring no coinsurance for most inpatient, outpatient, and emergency services. Inpatient hospital stays require a $295 daily copay for the first seven days and no copay for days eight through 90, while emergency room visits carry a $150 copay. Routine doctor visits are highly affordable, with no copay for primary care, a $30 copay for specialists, and no copay for annual physicals and fitness benefits. For supplemental care, this plan provides generous allowances, including up to $1,000 annually for dental services and $300 for eyewear with no copay or coinsurance. Prescription hearing aids are also covered up to $1,000 every two years with no copay, alongside routine hearing exams for a $20 copay. Major medical needs like dialysis and durable medical equipment require a standard 20% coinsurance with no copay, ensuring balanced coverage for essential healthcare needs.
Inpatient Hospital See details
Essence Advantage Choice (PPO) partially covers inpatient acute and psychiatric hospital services with a $295 copay per day for days 1 through 7, no copay for days 8 through 90, and no coinsurance. While unlimited additional days are covered, non-Medicare-covered stays and hospital upgrades are not covered.
Outpatient Services See details
Essence Advantage Choice (PPO) covers outpatient services with no coinsurance, featuring a $325 copay for outpatient hospital and observation services, and a $225 copay for ambulatory surgical center services. Outpatient substance abuse services require a $10 to $15 copay, while outpatient blood services are covered with no copay or deductible.
Partial Hospitalization See details
Essence Advantage Choice (PPO) covers partial hospitalization benefits, which require prior authorization before receiving care. Specific copay and coinsurance cost-sharing details are not specified for this service.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Essence Advantage Choice (PPO), with ground and air ambulance services requiring a $240 copay and no coinsurance. Transportation services to plan-approved and any other health-related locations are not covered.
Emergency Services See details
Essence Advantage Choice (PPO) covers emergency services with a $150 copay and urgently needed services with a $45 copay, with no coinsurance required for either service. Worldwide emergency services are partially covered, featuring a $150 copay and no coinsurance for worldwide emergency and urgent care, though worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage Choice (PPO) covers primary care, specialist visits ($30 copay), and therapy services ($40 copay) with no coinsurance, though podiatry services are not covered. Chiropractic care is only partially covered as routine chiropractic services are excluded, while telehealth options range from no copay up to $40. Mental health, psychiatric, and opioid treatment services are also covered with copays between $10 and $15 and no coinsurance.
Preventive Services See details
Essence Advantage Choice (PPO) covers preventive services, including annual physical exams, kidney disease education, and fitness benefits, with no copay and no coinsurance. However, these additional preventive services are only partially covered, as the plan excludes health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management, alternative therapies, therapeutic massage, adult day health, and in-home support.
Hearing Services See details
Essence Advantage Choice (PPO) partially covers hearing services, offering routine exams and fitting evaluations for a $20 copay and no coinsurance, and up to $1,000 every two years for prescription hearing aids with no copay or coinsurance. OTC hearing aids, along with inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are covered by Essence Advantage Choice (PPO), including one routine eye exam per year for a $30 copay and no coinsurance. Eyewear is partially covered with no copay or coinsurance up to a $300 annual limit, though eyewear upgrades are not covered.
Dental Services See details
Essence Advantage Choice (PPO) covers a wide range of preventive and comprehensive dental services up to a $1,000 annual limit with no copay or coinsurance. Medicare-covered dental services are also available under the plan for a $30 copay and no coinsurance, subject to prior authorization.
Home Infusion bundled Services See details
Essence Advantage Choice (PPO) covers Home Infusion bundled Services, including chemotherapy, insulin, and other Part B drugs, with prior authorization required. Covered insulin drugs require a $35 copay and between no coinsurance and 20% coinsurance, while chemotherapy and other Part B drugs have no copay and between no coinsurance and 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Essence Advantage Choice (PPO) plan with a 20% coinsurance and no copay.
Medical Equipment See details
Essence Advantage Choice (PPO) partially covers medical equipment, requiring no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes. Prior authorization is required for these covered services, and diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by Essence Advantage Choice (PPO), as lab services are not covered. Covered diagnostic procedures cost between no copay and a $35 copay, outpatient X-rays cost a $20 copay, diagnostic radiology ranges from no copay to a $200 copay (all with no coinsurance), and therapeutic radiology requires 20% coinsurance with no copay.
Home Health Services See details
Home health services are covered under the Essence Advantage Choice (PPO) plan, though prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Essence Advantage Choice (PPO) plan, as all associated sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are excluded from coverage, meaning there are no copays or coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Essence Advantage Choice (PPO), requiring prior authorization and excluding additional days beyond Medicare-covered stays. Covered stays have no copay for days 1 through 20, a $160 daily copay for days 21 through 100, and no coinsurance.
Other Services See details
Other Services are not covered under the Essence Advantage Choice (PPO) plan. This includes acupuncture, over-the-counter (OTC) items, meal benefits, and Dual Eligible SNPs, none of which are covered by the plan.
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